subject: Tips For Success In Transitioning To Ehr [print this page] Healthcare providers are starting to transition their medical records to Electronic Health Record (EHR) systems. This creates challenges related to time, cost and resources. This article will provide you with information about structured documentation.
Over the years, there have been many means of creating clinical documentation. Hand-written notes have given way to in-house dictation. Then in-house dictation found efficiencies and improved quality by moving to outsourced transcription services. More recently, some physicians have employed the use of self-service voice and speech recognition products to gain immediate access to their clinical documentation. Electronic Health Record (EHR) system adoption and enterprise requirements to collect data in anticipation of standardizing care have led to structure templates and a point and click style of collecting clinical data.
By enabling healthcare providers to capture specific clinical information directly from dictation narratives, clinical information results in complete and timely medical records. This is a vital tool that empowers physicians to capture clinical facts and orders (as opposed to just text) from dictation, without requiring any change to the physician's current dictation routine. Systems that support this advanced technology recognize and understand how to create structured and encoded medical documents.
What is structured documentation?
The clinical data contained in dictation can be shared across provider and system boundaries because our solutions are built around industry standards. Meaningful Clinical Documents are the key to making electronic health records truly interoperable and thus ensure more effective orders and treatment, enhance clinical decision support, outcome analysis and clinical research and ultimately improve the quality of care and patient safety.
Most transcriptions are text documents with formatting, usually stored as RTF or Microsoft Word documents. While the text documents may have section titles and data in them, the information is not structured in a way that a computer can easily identify it. For example, the text may say "blood pressure was 130 over 90" but a computer would not be able to identify the blood pressure and the numeric values in order to act upon them or send them to an application that understood the data. Structured documentation allows the information to be clearly identified and shared. It defines how a file should store important measurements and medical facts so that they can share the information and it can be used by other software programs.
This is particularly relevant as EHR systems become more popular. EHR systems store structured data that comes from a patient visit. An EHR system can import a meaningful clinical document to create the patient visit record. The physician could accurately record measurements such as temperature and blood pressure through dictation.
Transcription & EHR: The Perfect Pair
What if physicians could continue to dictate while experiencing the benefits of EHR? Critical to the success of electronic health records is an emphasis on provider productivity. First, physician's practical need for a fast and easy method for creating clinical notes; and second, the enterprise need for structured and coded information capture. The nirvana of creating clinical documentation has not been realized - until now.
Discrete Reportable Transcription (DRT) allows physicians to resolve these two opposing needs and use EHRs in conjunction with narrative dictation. The clinical document is created and encoded and easily populates any EHR. Robust data is created and the physician's time is reserved for clinical care. In fact, in a study by AC Group involving 573 patient charts, DRT-enabled EHRs averaged 30 minutes per day in clinician documentation time while standard EHR data entry (point and click) took 140 minutes per day.
