A recent study in the Journal of American Informatics Association found that when dictation is relied on for EHR documentation, providers have much lower quality scores than when they input data into the EHR manually. Speed has a lot to do with this. Regardless of accuracy, it is quicker to dictate a note than it is to plod through a structured template of pulldown menus and checkboxes when caring for a patient in a busy hospital or clinical environment.
The EHR is still in an evolutionary phase. We seem to have more tools than we've ever had, with solutions sometimes seemingly looking for a problem to solve. In our practice, we have used a tablet-based EHR for the last couple of years. In our community hospital’s EHR, there are lots of templates that help a provider properly document the various conditions confronted on a daily basis. We also have a dictation module within our EHR for speeding up the narratives that are always required in medical documentation.
As clinicians, our procedure-laden environment would benefit from a template-based approach to documenting the procedure. Our EHR has an especially rich library of procedure templates that make accurate and comprehensive documentation a slam dunk. Informed consent; risks benefits and alternatives; key elements of the procedure; and patient education and follow-up can easily be documented using these templates. With these tools, the nuances of the procedure can quickly and efficiently be documented in a busy environment.
Why don’t more providers avail themselves of these readily available tools? The answer to this question is complex. There is a learning curve to using these prepared templates, and that curve ranges from just finding them within our complex system to learning how to best use them in an efficient manner. Beyond the initial training that every provider was mandated to attend on the use of the EHR at implementation, there is no program within our facility to improve the EHR literacy on an ongoing basis.
Getting busy clinicians to make ourselves available for training on electronic tools in the practice of medicine is a major challenge at every institution, with no easy answers or solutions. Enhancing technological literacy among healthcare providers is becoming a significant priority as reimbursement becomes increasingly tied to documentation and quality measures.
Quality measurement is also becoming increasingly important to every aspect of the delivery of healthcare in the United States. From quality improvement to reimbursement, accurate and comprehensive data is becoming more crucial within the healthcare system. The accuracy of that data is critical to ensuring people receive the highest level of care and that the care is properly documented for reimbursement and other financial reasons.
We must find a way to bridge the gap between the tools available and their utilization within the delivery of healthcare. We have multiple generations of competent, dedicated providers, who were raised and trained in the era, before the widespread use of computers in healthcare. The younger generations of PAs, physicians, RNs, NPs and other providers are being trained with the skills needed to practice effectively in the modern, technological healthcare system. For all others, we need to work together to provide significant training and technology support resources to facilitate our transition to the new world of technology in medicine.