Technology tips to improve your clinical documentation process

While the future holds promise for a health care system in which all records are stored electronically, what technologies are readily available today? A wide array of tools currently available can produce digital documents while streamlining your clinical documentation process. Which ones are right for your practice or clinic? Here are five technology ideas that can increase physician satisfaction and improve workflow without requiring a large dollar investment.

1. Use a web-based platform for document exchange

Converting to a web-based platform is one of the easiest changes your practice can make to speed document exchange, and in most cases requires absolutely no upfront cost. With online, secure document storage, a web-based platform can serve as a basic electronic medical record system for tracking and retrieving patient records.
Turnaround time on transcriptions is typically much quicker, as documents are available online as soon as transcription is completed, often the same day. This aids other clinicians in the continuum of care and can speed production of the patient bill.

Physicians love that they can create and retrieve clinical notes at any time of the day or night and from any location with internet access. Your administrative staff will appreciate that they can quickly locate and retrieve completed notes without having to call the transcription service to have a document resent.

2. Automate schedule downloads to your transcription platform

Create an interface to automatically download your daily patient schedule to your transcription platform. This improvement will require a small investment in software development fees, but is well worth it for the downstream benefits in productivity.
One of the most common reasons that clinical notes are held up is because a transcription service is unable to match a dictation to a specific patient medical record and visit. Hours and hours of transcriptionist and administrative staff time can be spent weekly trying to track down this identifying information. An automatic download from your scheduling system ensures that this information is available from the moment the dictation is received.

An additional benefit is that you can eliminate a common source of lost records by matching the day’s schedule against completed dictations. How often have you heard “I think I dictated that patient but can you check” several weeks after a patient visit? Or have you lost records because the demographic information in the dictation was wrong, so that even though the note was created it cannot be found? With an automatic schedule download, you can eliminate these causes of lost documentation.

3. Make front end speech recognition available to your clinical staff

Front-end speech recognition is a great tool for physicians who are interested and highly motivated to use it, but don’t expect it to be the solution for everyone in your practice. Physicians must see a personal benefit from using speech recognition.
In our experience, by far the most powerful motivator has been the ability of a physician to increase income by reducing transcription costs. Good front end speech software that has been customized for your medical practice can cost $200 to $300 per month per physician, which can be a significant savings for high volume dictators spending $1000 per month or more on transcription services.

A note of caution: there are many copies of off-the-shelf speech recognition software sitting unused in medical practices throughout the country. Consider using a vendor who knows the tricks of the trade for using front end speech successfully in a medical practice, and who can ensure that notes created with speech recognition are transferred and stored with other documents on your central system.

Benefits of speech recognition include being able to produce signed notes quickly for patient care and billing use. An H&P exam can be completed and dictated the evening before surgery, and available online the next morning at the surgery center. Specialists can generate referrals from primary care physicians who are impressed with the speed with which completed consult notes are delivered.

Do not expect speech recognition software to completely eliminate the need for medical transcription. The best clinical applications for a self-edited note are those in which templates and macros can be used to limit the amount of dictation that the speech recognition software must capture. Otherwise, your clinical staff can spend valuable hours editing patient notes, when there are others more qualified to do so.

It is also useful to have back-up transcription support to complete more complicated notes such as comprehensive patient exams and for catching up on backlogs. Speech recognition does not typically reduce time spent on dictations: at best it is time neutral.

4. Use medical editing to free up clinical time

While images of fingers flying across the keyboard may first come to mind when thinking of medical transcription, transcriptionists also serve a vital role as editors of medical documentation. As direct entry of patient information by physicians and other clinical staff becomes more prevalent, consider providing medical editing as part of your documentation service.

It is far more cost effective to have a medical transcriptionist edit clinical documents than to have your highly trained and compensated clinical staff doing so. Medical transcriptionists (also referred to as medical language specialists) are also an important member of the patient care team, as they edit clinical notes for accuracy, which is critical for legal documents.
If you currently use or are considering an electronic medical record system, you have probably discovered that the biggest implementation challenge is to make it easy for clinicians to document patient visits. Point and click data entry is effective for some data elements within the patient note, such as the subjective and objective findings of the SOAP note (subjective, objective, assessment, plan). The assessment and plan, however, are not well-suited to structured data input, as their main purpose is to document the physician’s thought process in determining a course of treatment. (Medical malpractice carriers frown on “cookie cutter” notes from EMRs for this reason.)

One approach is to create a dual system for EMR clinical documentation in which point and click data entry by your clinicians is combined with free text notes edited by medical transcriptionists. Free text notes can be created by several methods, including 1) standard dictation, 2) front end speech recognition, or 3) keyboard entry.

The key is to let each member of your medical staff select the process best suited to efficiency for his or her style, and then employ medical transcriptionists to edit free text notes and format documents for final use.

5. Capture discrete data from your transcribed notes

Beware of the “technology tail wagging the dog” when setting up a system for capturing discrete data on patient visits. In too many instances we ask physicians to change their practices to conform to the limitations of our software, when instead we should be developing technologies that support how physicians practice medicine.

A prime example of this is requiring physicians to use point and click fields because it is the easiest way to capture discrete clinical data. A better alternative available today among more advanced clinical documentation systems is XML tagging. XML (short for extensible markup language) is used to create customized data tags that can define and capture a variable from free text such as a Word document. The captured data can be exported to data fields within an electronic medical record.

XML tagging provides the benefits of both types of clinical documentation, as it preserves the narrative description while creating searchable data for each patient visit. Best yet, physicians are free to use dictation, which is still the preferred method of note creation. Your technology now accommodates your medical staff, and not the other way around.
XML tagging doesn’t have to be expensive. Look for transcription companies and electronic medical records vendors that offer this technology as part of their clinical documentation services.

About MD-IT

MD-IT is a transcription company specializing in advanced clinical documentation services. We combine the benefits of local office ownership with the resources of a national company to offer personal service supported by leading technology. MD-IT serves physician practices and ambulatory clinics where we believe having a personal connection is still important. We take the time to learn the preferences of your clinicians, and to understand your goals for electronic medical records, so that we can provide the right combination of services and technology for your practice.