submitted by:
Donna Barnard, RHIA
Director of HIM, University of RochesterMedicalCenter
&
Linda Yaniszewski, CEO/President, ExecuScribe, Inc. (pictured below)
The University of Rochester Medical Center (URMC) is moving to a completely electronic health record (EHR) and as a result their provider documentation will change-this is guaranteed. What is unknown is exactly how providers will adapt to new ways of capturing data and documenting encounters.
Provider documentation, captured primarily by dictation and transcription today, faces a future where reports will be created using a hybrid blend of technology and service options including dictation, transcription and EHR templates.
Provider Documentation is EHR's Biggest Challenge, Transcription's Greatest Strength
Transitioning providers from traditional dictation and transcription to electronic, template-based documentation is one of the greatest challenges for EHR implementation teams. Perhaps this is why there are less than 25 HIMSS Stage 7 hospitals nationwide (where all providers must document within the EHR).
At URMC, computerized provider order entry (CPOE) and electronic nursing documentation were already implemented. Selection of the next generation EHR focused on a patient-centric electronic, template-based provider documentation and the structured, discrete data that will result. The organization is starting with a difficult step for any organization installing an EHR and the important point for medical transcription collaboration.
Because provider documentation is such a critical part of their EHR strategy, URMC decided to involve their transcription partner, ExecuScribe, early in the process. ExecuScribe representatives began attending EHR strategy meetings as early as 2009 and are still included in many provider documentation discussions.
By involving their transcription vendor early in EHR planning, URMC has already learned three important ways transcription companies can help. They are:
- Provider documentation experts with hundreds of standard templates in place.
- Safeguards for quality documentation.
- Technology specialists who bridge the gap from legacy dictation systems to new EHRs.
Three Reasons to Get Your Transcription Company Involved
Transcription companies have been processing and managing provider documentation for decades. They have hundreds of report templates already in place and already know the finer nuances of each provider's documentation patterns and preferences.
By working together, HIM departments and transcription companies can achieve an important organizational goal: improve provider satisfaction as documentation moves from transcription to EHR templates, not abandon it. Specific strategies used by URMC to maintain high levels of provider satisfaction include:
- Continually emphasize that the EHR is a clinical project, supported by IT. Not an IT project supported by clinicians.
- Involve clinicians in every step. They will be the ones using the record and must be the architects in designing how it will look in the future.
- Help them rethink documentation. For example, discharge summaries are no longer static documents to be completed and finalized. They are now a dynamic compilation of data generated throughout the entire care process.
Maintaining Documentation Quality in an Electronic World
ExecuScribe has served as URMC's medical transcription and clinical documentation partner since 1998. Over the years, they have earned the reputation for continually exceeding expectations for quality, timeliness and customer support. In transitioning to an EHR, URMC providers will expect the same quality and service levels. Expectations will remain high and the need for complete accuracy and timely report turn-around doesn't go away in an electronic world. Paper, electronic or both, this is still the legal medical record.
Furthermore, narrative reports will continue to be an integral part of healthcare. And as long as some narrative exists, the need for documentation safeguards will remain. URMC will continue to rely on the experience and quality service provided by their transcription vendor throughout the transition.
Transcription Companies Serve as "Plan B" when Legacy Systems Fail
The technology available through a transcription partnership also helps bridge the gap between legacy dictation systems and provider documentation within the EHR. For many hospitals, dictation systems are antiquated and maintenance fees are high. A solid transcription partner provides a reliable "plan B" for system downtimes.
In addition, other organizations that have implemented an EHR report declines in provider satisfaction when template-based documentation is installed. Industry experience shows that some providers will continue to want to dictate up to 30%, according to recent reports. Many have learned that 100% compliance with drop-down menus and templates may be unrealistic, despite the best-made plans.
In these situations, transcription companies can provide speech technologies integrated within the EHR along with medical editors to help bridge the gap. EHRs can be dictation-enabled as an alternative for change-resistant or time-constrained providers. If a busy orthopedic surgeon or cardiologist needs only 2 minutes to dictate a report, but 6 minutes to point and click, there will be challenges. During the time it takes to reduce the time difference in these functions and show the value add to codified data, transcription services can help fill the gap.
Clinician Involvement is Critical in Every Phase
URMC has thought ahead when it comes to clinician challenges. They have emphasized clinician involvement throughout every step of EHR planning. It is a clinical project with information technology (IT) support. Not the other way around.
Clinicians must steer the direction of "what" the new medical record will look like as they will be the primary users of the "new" medical record. Furthermore, clinician satisfaction is extremely important at URMC. Medical records generated by an EHR look much different than their paper-based predecessors. It takes an adjustment and clinicians must be on board.
While the ultimate goal is to get every clinician (physicians, nurses and all ancillary services) to document within the EHR, the organization is taking one step at a time. All nurses and ancillary departments that currently document electronically will convert to documentation within Epic as part of Phase I, scheduled to go live March 2011. Providers will also begin documenting progress notes, history and physicals, consult notes, and discharge summaries within the EHR in Phase I.
There will still be places for free text, subjective input from providers within the discharge summary. However, the majority of the document will be created as a byproduct of data captured throughout the patient encounter. Structured data will then be used to evaluate care patterns and outcomes across patient populations within URMC.
Operative reports will be still be dictated in Phase I with some EHR templates used for routine, standard procedures.
Final Thoughts, Words of Advice
For every piece of clinical documentation that will be created through the EHR, it is important to ask "who" will be impacted by the change and being the lines of open communication and education. Transcription companies are the closest to provider documentation today, and have been for decades. It is crucial that they are included in EHR planning and transition discussions, especially as is relates to provider documentation and satisfaction.
Finally, technology available through a transcription vendor should be in place to cover all the various "what if" scenarios. A solid back-up plan and transcription partnership eases the transition while providing a reliable safety net for change.
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