Of Physician Documentation--And Disaster Recovery

Right now, here, we live in this world that remains a mix of electronic and paper notes. And on average, you can’t read half of the paper note. And the part you really need to evaluate from the consulting or attending physician, you can’t read; so that part speaks for itself. We have gone live with physician documentation, but there’s still a fragment who are documenting partly on paper; in September, we end all that. At least half of our notes on the inpatient side are being done electronically, and half aren’t; we’re getting ready to do a big bang—we’re “partially pregnant” for CPOE [computerized physician order entry] and physician documentation, and when we flip the switch, we’re going to go full-out.

We’re getting ready for Stage 2 of meaningful use; Stage 1 required only 20 percent of your notes to be electronic. So with traditional dictation, the turnaround rate is fairly slow, and the error rate is fairly high. The docs who are typing their notes—I think that is helpful, since I can see those notes in real time and anywhere. It’s frustrating, to some extent, because some of them don’t write a significant amount—they’re using templates, and the notes can be somewhat cookie-cutter, so you’re losing some of the patient’s story—you’re seeing aspiration pneumonia, for instance, and you’ve just initiated treatment with two antibiotics.

And a lot of times, traditionally, you’d elucidate your thought process, and those types of subtleties tend to go away when the docs type in their notes, because of the time involved. So some of the story is lost and some of the artfulness of the notes is lost. So with PowerMike with Dragon in Nuance, the docs are still using the templates, and that supports meaningful use; but the nice thing is that the story and the subjective is better, because there’s more narrative-type text. And then the physicians put in their thought process more, because they’re speaking.

The deeper challenge in this is that we’re dealing with a culture change; we’re asking the physicians to change what they’ve always done. And physician documentation is one of the hardest elements, because a lot of them can’t type. So the ER docs were hesitant at first, but they’ve liked it. I’ve had one doc who’s chronically on suspension because of not getting his notes done, but on Nuance now, it’s not been a problem. And this will save us a million dollars a year; we see 100,000 visits a year to our ER. We had ERs in all three; the main ER is on our main campus, the Porter Campus.

So it’s not just about the ability to type, but how many tasks the doctors need to accomplish, that makes speech recognition necessary, then, correct right?

Yes, it’s a combination of things; you’re dealing with two or three patients on the same floor, dealing with nurses, trying to take notes, trying to enter orders, all at once. And the note has just become such a laborious thing—and frankly, the note is primarily documentation for Medicare, to prove we’re not committing fraud; and for medical-legal purposes for the attorneys; and with the templates, it becomes very routinized, and what the doctors are trying to input themselves becomes minimized; and with having to do so many things at once, that’s hard. The older physicians will certainly embrace speech recognition, because they’re not having to type. But for the younger physicians, it’s about better workflow. Me personally, I can type like the wind; but I was starting to get some carpal tunnel syndrome. Two hundred e-mails a day, and constantly typing in notes; that’s a real challenge. So I absolutely love our speech recognition solution, and my nurse loves it, because when I do a telephone message back, my thoughts are in there. And the nurse practitioners like it, because they get more of the subtlety.

So they’re reading these notes that you had automatically gotten into the note via the speech recognition solution?

Yes, and that’s nice, because let’s say they’ve got a new penicillin allergy; I’ve dropped that into the note;  and if they’re allergic to sulfa, I’m going to start doxycycline, and the nurse will know that. And it works in the workflow, and brings back the subtleties we need. We’re not going to get away from these templates anytime soon, but the artfulness can be retained. So that’s what you’re gaining with Nuance and real-time voice-driven notes.

What would your advice for other CMIOs be, regarding moving forward on physician documentation issues?

I think that using voice-to-text is really the answer to the pushback that electronic documentation is cookie-cutter and that the notes become redundant and that the story is lost. Voice-to-text is the answer in terms of bringing those nuances back to the notes.

Is there anything the industry can do to further optimize the physician documentation process?