Doctors who dictate their clinical notes before they're entered into an EHR have lower quality of care scores than those who type or enter structured data directly into the EHR, according to Partners Healthcare researchers.
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Switching to an electronic health record (EHR) doesn't always improve quality of care. To understand why, researchers at Partners Healthcare in Boston analyzed the different ways that doctors, using the same EHR, document their care. They found that physicians who predominantly dictated their notes had lower quality scores than those who typed their notes or used drop-down check boxes to enter their findings in a structured format.
In their study, published in the Journal of the Medical Informatics Association (JAMIA), the researchers examined records of 7,000 visits to 234 primary care doctors in the Partners system over a nine-month period. All of the patients who made these visits had coronary artery disease (CAD), diabetes mellitus (DM), or both. The study looked at how well their physicians did on 15 measures of quality in treating these conditions and then correlated that with their method of documentation.
Of the physicians in the study, 9% mainly dictated their notes, 29% predominantly used structured documentation, and 62% typed their notes as free text in the EHR. While there were mixtures of these styles, a physician was classified as a user of dictation or a user of structured data entry if he or she utilized that method more than 25% of the time.
Overall, quality of care was worse for physicians who used dictation than for those who used the other two approaches. The dictating doctors came out below the other groups on three of the 15 measures, while structured-entry doctors surpassed the other cohorts on three measures. On none of the metrics did dictation users get better scores than the other physicians did.
The researchers offered two explanations for these results. First, they said, physicians who used structured EHR templates to document their findings were less likely to miss necessary steps in patient care than were doctors who dictated. Second, physicians who interacted with the EHR--rather than simply dictating notes that would be placed in it later--had the benefit of clinical decision support tools imbedded in the EHR.
One of the most striking findings in the study was that less than a third of the EHR users entered structured data. Such a result might be expected in a physician group that had only recently switched from paper to electronic records. But Partners Healthcare has been using its homegrown EHR, known as the Longitudinal Medical Record (LMR), for many years. So what the research found was not the result of inexperience with the EHR, but of physicians' longstanding, ingrained resistance to clinical data entry.
Indeed the JAMIA study discovered that, of the three groups, the physicians who used structured documentation methods were the least satisfied with their note-taking method.
The main reason why so many of the physicians didn't enter structured data in EHRs is that "it slows them down," said Mark Anderson, a health IT consultant based in Montgomery, Texas. His own research among clients indicates that it takes physicians nine times longer to document visits in EHR templates than it takes them to dictate the same notes.
Consequently, he said, dictation remains a major data-entry method in many practices that use EHRs. In fact, medical transcription services have seen no downturn in their business due to the growth of EHR adoption, he noted.
In most cases, physicians "don't need the data [in their documentation]," Anderson said. "They just want to get the note done. Physicians need lab results, pharmacy, nursing notes, social history, and so on. The doctors don't put any of that in. The results come from the lab. They may do electronic prescribing--but that's not notes, it's orders. Compared to the amount of time required to enter structured data, it's much quicker to dictate, and it's probably two or three times as quick to type it in."
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