Dictating Notes Into EHR Linked to Poorer Care

May 31, 2012

May 31, 2012 — It makes a clinical difference how patient data get inside an electronic health record (EHR) system, according to a new study published online in the Journal of the American Medical Informatics Association earlier this month.

Physicians who dictated into their EHRs saw twice as many patients per day than those who either entered information in a structured way (think templates and data fields) or typed free text. However, the quality of the dictators' patient care was poorer, according to lead author Jeffrey Linder, MD, and coauthors Jeffrey Schnipper, MD, MPH, and Blackford Middleton, MD. All 3 authors are assistant professors of medicine at Harvard Medical School in Boston, Massachusetts.

Dr. Linder and coauthors analyzed almost 19,000 patient visits in 2007 and 2008 with 234 physicians affiliated with Partners Healthcare, a healthcare system based in Boston. The patients had coronary artery disease (CAD), diabetes, or both. The Partners physicians used an EHR that was outfitted with a software tool that helped them document visits for patients with CAD and diabetes and that provided clinical decision support. That support came in the form of reminders about overdue preventive services, alerts about drug interactions, and suggested treatment options.

Of the 234 physicians, 9% tended to dictate their visit notes, 29% primarily used structured data entry, and 62% were free-texters. All the dictators were attending physicians. Residents and fellows accounted for 44% of the structured-data camp and 54% of free-text physicians.

The study authors graded the EHR users on 15 quality measures pertaining to CAD and diabetes. According to what was captured in the electronic charts, the dictators significantly lagged behind the other physicians on 7 of the 15 measures. The dictators were less prone, for example, to prescribe antiplatelet drugs to patients with CAD, and far fewer of their patients with diabetes had had eye exams in the previous 13 months. Dictating physicians kept pace more or less with the others on the remaining 8 measures, such as cholesterol testing and glucose control, but never led the pack.

By far the best-quality outcomes were achieved by physicians who entered structured data that automatically populated the EHR database. They posted the highest scores in 10 of the 15 measures.

Older Physicians Chose Easiest Method to Enter Data

The study highlights long-standing and nettlesome issues regarding physician adoption of EHRs.

Surveys over the years have reported that physicians who grew up using computer keyboards are more likely to use the technology on the job than older physicians who first processed words with pencils and typewriters. Not surprisingly, Dr. Linder and coauthors found that physician dictators were an average of 52 years old, which is roughly 15 years older than those who entered structured data or typed free text into the EHR.

Of the 3 data-entry methods analyzed, dictation qualifies as the easiest, because it does not require physicians to even log in to an EHR. All they need to do is speak into a digital recorder and let someone else transcribe the dictation and upload it into the EHR as free text, according to the authors.

In contrast, plugging patient information into numerous data fields is interaction with an EHR at its most intense. The authors write that in a separate study of EHR use at Partners Healthcare, structured documentation was the least satisfying method of data entry among physicians. That finding mirrors widespread complaints by physicians that working with template-based EHRs makes them feel like clerks.

However, the form-fillers generally outperformed everyone else on quality measures in the current study. The reason, the authors surmise, is that they paid more attention to coded data fields with missing information and had more of an opportunity to see and respond to prompts, alerts, and reminders.

For the sake of improved patient care, the authors recommend that designers of medical software make structured data entry more user-friendly to win more physicians over to this method. There is also a possible fix for dictated and free-text notes: a not-yet-prime-time technology called natural language processing that automatically pulls structured data out of a mass of words.

The authors have disclosed no relevant financial relationships.

J Am Med Inform Assoc. Published online May 19, 2012. Abstract

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