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April 2016

Words Matter: Best Practices for Dictating in an EMR Setting
By Selena Chavis
For The Record
Vol. 28 No. 4 P. 14

As HIT matures, dictation and transcription models continue to evolve. It's a situation being closely monitored by health care organizations concerned about the fallout from potential productivity losses and physician outcry over clunky EMR documentation workflows. To combat these fears, many facilities are considering models that incorporate dictation back into the fold.

"I think one of the primary reasons organizations make the switch is that they have provider dissatisfaction," says Billy Allred, director of IT and business development at Pennsylvania-based Opti-Script. "They have providers upset that they are spending three and four hours a day entering notes."

While physician satisfaction is one part of the equation, productivity looms just as large, says KB Anand, CEO of Pennsylvania-based Acusis, noting that losses in that regard impact the bottom line and catch the eye of the C-suite. "Having an option to dictate helps physicians maintain productivity, especially in specialties like cardiology where extensive documentation is required, but at the same time, every minute of the cardiologist's [time] is money," he says. "So the question is where to spend that time. A cost-benefit analysis will easily advocate the physician doing a quick and easy dictation and moving on to the next patient rather than spending additional time point-and-clicking or struggling with the structured templates in an EMR."

Anand also points out that specialties such as psychiatry require greater narrative than can be provided by structured documentation fields. This need for greater detail can't be met in a controlled context, he adds.

Opti-Script President Sharon Allred, CMT, AHDI-F, says that health care organizations are challenged in their efforts to balance physician productivity with legislative and fiscal obligations. She recommends adopting best practices to incorporate dictation models or face the consequences of documentation errors and omissions that can impact patient safety and revenue.

Industry professionals agree that regardless of how the final document is produced following dictation, there must be quality assurance (QA) in place to ensure accuracy and completeness for patient care and coding. For instance, Bryan Medical Center in Lincoln, Nebraska, has instituted a QA program for their providers and trained medical transcriptionists (MTs) to work as trainers and analysts.

"QA is essential," explains Leigh Anne Frame, HIM manager at Bryan Medical Center, "QA of the report itself, but also checking that [clinicians] used the right template, inserted it into the right location in the EMR, identified the right patient, etc. In the beginning, we did 100% QA, and then we tapered off."

As health care organizations consider the best models for dictating into an EMR, industry professionals offer guidance on sound practices and potential pitfalls to keep watch for.

Do Get Clinician Buy-In
Frame emphasizes the importance of gaining clinician buy-in when implementing a model for dictating into an EMR, whether an organization employs traditional dictation and transcription, front-end speech recognition, or a hybrid model. For Bryan Medical Center, identifying the right approach proved challenging.

"I'm still trying to find that happy medium," Frame acknowledges, noting that clinicians initially agreed on a "once-and-done" solution for their dictated reports. "Even though we provided very good turnaround time with traditional dictation, by the time we transcribed it and [clinicians] went into the EMR and edited it or signed it, the turnaround was obviously extended by quite a bit. Even though it might take them longer up front, they felt it would save time in the long run, and that turned out to be true as we monitored it."

According to Sharon Allred, a key ingredient to clinician buy-in is allowing providers to choose their workflow. Accomplishing this goal requires flexibility in how dictation is offered as well as the provision of a validation function behind the dictation model for QA.

Sherry Doggett, an industry veteran and former president of the Association for Healthcare Documentation Integrity, agrees. "Offering clinicians full or partial dictations within the EMR encounter allows choice, and if they have a difficult case, dictating either full or partial dictations allows for more robust documentation," she says. "Partial narratives are ideal because the clinician can use the templates and drop-down boxes within the EMR but [also] add the patient's story, which is so important."

Don't Make Assumptions About Quality
While speech recognition technology has come a long way in the last decade, few in the industry would suggest that it's foolproof. Sharon Allred says that trying to accomplish dictation goals without a validation piece in place is a sure way to create an opportunity for both minor and critical errors. "Patient safety is potentially compromised in that regard," she says. "Just leaving out a 'not' or 'no' is critical in a lot of situations."

Billy Allred notes that providers often overestimate the quality of their dictation, believing that minus a few commas and periods, it's probably in pretty good shape. In his experience, the reality is much different. In fact, a recent client analysis revealed that 11% of provider work contained a critical error. "Just because a provider thinks they are doing a good job or just because an office staff person peruses the document ... doesn't mean data are accurate and complete to the level needed for coding," he says.

For example, one recurring issue that Doggett has noticed is that physicians are not pulling up the correct encounter within the EMR. "It is easy via traditional dictation [into a digital system] to correct if caught at the point of transcription," she points out. "Unfortunately, if the clinician chooses the wrong encounter, it is much more complicated to place within the correct encounter. This can occur with full dictations or partial narratives."

Do Consider the Technological Framework
EMRs are here to stay. But instead of resisting any new workflows the technology may introduce, Anand recommends learning how to dictate properly to produce the best documentation. This starts with being sensitive to the capabilities and limitations of the EMR being used.

Frame suggests that a high-quality speech microphone is essential to good voice recognition. "If you have the clinician's buy-in, they will look at the words appearing on the computer screen, but they don't always pay attention to content," she says. "So, the [voice] recognition needs to be as good as it possibly can be."

Equally important is the functionality of the front-end speech recognition software, Frame says, pointing to user-friendly yet robust offerings that make it easy to create and use shortcuts, expanders, and text inserts. "Just as important as the front-end speech recognition software is the computer itself," she adds. "We found conflicts with some applications that are Citrix based. The speed and amount of available memory on the PC is very important, as is the network connection. If it isn't consistently fast or if the network connection is slow or often lost, even for a split second, clinicians will be frustrated, and it won't be long before they'll quit using it altogether."

Once the infrastructure is in place and limitations are identified, Anand suggests that dictation provide as many details as possible that can be integrated back into the EMR to ensure quality documentation for analytics is present and ICD-10 requirements for specificity are met. "If the details are not provided, then every other patient case looks the same, and the reporting becomes cookie-cutter and stereotyped, which is against providing individual and personalized care for each patient," he says.

While specifics are important, Anand cautions that providers stay away from dictating details that cannot be captured into the target EMR. While transcription may pick up those details, if there is no field for them in the EMR, they cannot be subjected to further use or coded and billed. "EMRs in general accept data in discrete blocks once it is transcribed rather than as a narrative," he notes. "So, the dictation should result in a transcript that can produce these discrete elements, and the physician should adjust his habits that support it."

Anand says it's worthwhile for health care organizations to investigate technology advancements such as "narradata," which produce discrete data from the unstructured narrative reports and can be electronically or manually synched back to an EMR for meaningful use and core measure reporting.

Don't Skimp on Education and Training
Frame underscores the importance of training clinicians on proper dictation methods, suggesting flexible options that are catered to different learning styles. "One size fits all does not work," she says, adding that training should be held onsite by the vendors as part of a workflow model. "Webinar training does not work well when training front-end speech recognition with clinicians. It's also best to have two trainers: the vendor to do the [speech recognition] training and someone from within the facility to do EMR training."

Sharon Allred points out that as traditional MTs transition to new roles as editors and health care documentation specialists, they must be educated on general coding issues and critical documentation elements. "It's not that they have to be a coder, but they have to understand the role the encounter's documentation plays in reimbursement and patient care," she says. "There is a lot of critical thinking required."

For example, in ICD-10, fractures now must be documented on various levels. Without this specificity, providers will find it difficult to obtain the proper reimbursement.

Anand recommends that MTs be trained on best practices for the dictation itself. "Once the dictation is converted into a transcript, it contains two types of data: data that have a place inside a specific data capture element inside an EMR and data points that are orphans which go into the EMR as free text," he explains, pointing out that while it is easier for an MT to convert any part of the documentation as free text, they should avoid this path. "Free text should be entered only when the specific EMR does not have an option to capture a dictated data point. Omitting it makes the report incomplete, and the MT's knowledge about the target EMR's capability becomes vital in these situations."

Industry Complexities
While there are advantages to dictating in an EMR, there are limitations. For example, vendor nuances can make interfaces with transcription and QA more difficult. "Often the client is left to make the best of the situation," Sharon Allred says. "It requires that our IT staff be much more competent and knowledgeable about interfacing.

Anand points out that lack of standardization among EMR vendors makes life more difficult for physicians. "For example, if you look at the interfaces that each EMR system provides to enter a progress note, they look different," he explains. "Vendors implement EMR features differently, and a physician moving from one EMR system to another has to struggle to interact with the new one in the new format if they want to switch systems."

Sharon Allred notes that the variances between EMRs require third-party services to take more of a partnership approach with clients to ensure the most effective documentation and output quality. For this reason, Opti-Script conducts a complete analysis of workflows to determine the best approach, taking into consideration physician preferences and documentation practices to ensure the organization can work collaboratively to elevate documentation.

"For us, it's harder to get decision makers to stop and think that there has to be a better way," she notes. "They have listened to EMR vendors say, 'This is so easy' [in relation to EMR dictation]. They are placing unrealistic expectations on their providers, and they think technology can do it all."

Anand says allowing some form of dictation in an EMR environment makes the most sense. "Health care provider organizations that went into the hybrid approach—allowing physicians to use an EMR to enter data directly while giving them an option to dictate—are better off than those who went the hard way of shutting the door of dictation altogether," he says. "The learning curve of the physicians while adopting EMRs has been significantly lower for those who had an option to dictate when needed. For those physicians whose time is super critical, the return on investment is always better using a transcription service than forcing them to spend additional time in documentation."

— 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 health care and travel.