Speech Recognition as the Accelerator of Meaningful Clinical Documentation

Hello everyone: Over the last couple of weeks I had the opportunity to attend several conferences. One was the national conference of the Case Management Society of America (CMSA) (more about this visit later) which was held in San Antonio, Texas, (home of the Alamo). Then I had the privilege of presenting to two state HIMA conferences; New Jersey (NJHIMA) in Atlantic City, and then back to Texas (TxHIMA) for their state conference in Dallas.

As always, I really enjoyed meeting with state HIMA members. It is so satisfying to know that wherever you are in the country, HIM professionals have the same passion for safe, high-quality, useful health information. It is also interesting to see that everyone seems to be facing the same challenges with respect to adoption and use of electronic health records. Everywhere I go, I hear the same stories about point-and-click, template-driven EHR systems that are time-intensive and cumbersome for the physician, that don’t provide the necessary information for the HIM, and which cause concerns for the health care enterprise because of costs and questionable ROI.

Needless to say, there is always interest in discussing narrative documentation including how to produce it cost-effectively and efficiently, and how it can be used to generate the discrete data needed for the interoperable exchange of information, to provide data for reporting and analysis, to drive clinical decision support and other automated care protocols, and in general, to realize the benefits that we all expect as we make use of electronic health information.

Some of you have seen these before, but just in case, here are my slides:  NarrativeDocumentation_HIMA_20110629.

In a nutshell:

1. Today’s changing health care environment is setting higher standards for documentation while seemingly making it more difficult for physicians to document patient care. The need for documentation to support Meaningful Use, to drive the communications and reporting necessary for Accountable Care and the Patient-Centered Medical home, to enable the conversion to ICD-10 from ICD-9, and to support the reporting required to monitor quality and outcomes is increasing. It is more apparent than ever that comprehensive, complete, and accurate health information is integral to the functioning of any health care facility. And yet newer methods of documenting patient care are often inefficient and time consuming for the physician and are not intuitive for other consumers of health information.
2. Dictation is still a viable, economical, and effective means of capturing clinical information.
3. In order to be cost- and time-effective, options for clinical documentation must be made available based on the type of encounter being documented and the needs of the user. For some encounters, templated, structured forms are likely sufficient. For others, physicians may do very well with speech recognition and self-editing. For more complex encounters, physician dictation supported by skilled medical transcription might still be the best way to go. The point is – health care providers must have flexibility and options for capturing the complete, comprehensive level of information required to support patient care, coding for billing and reimbursement, research and population health reporting, and all of the other uses for health information.
4. Speech recognition and other technologies, when combined with efficient management practices, can be a cost-effective way to produce high-quality narrative documentation.
5. We cannot continue to look to the best practices that many services and providers have historically followed when implementing speech recognition. In the past the goal might have been to “create cheap documentation fast” – now the goal for clinical documentation MUST be, “create useful documentation efficiently.’
6. Quality is key. We are all hearing a great deal about natural language processing, computer assisted coding, and other technologies that will help us to process and make use of our health information – but if the documentation at the foundation of these technologies is poor – the technology can’t do its job.
7. Efficient management practices are another key component. The percentage of productivity gained does not necessarily reflect the increase in output! Again, technology is no replacement for effective management practices.
8. It is not, as many believe, necessary to eliminate narrative documentation in order to have semantically interoperable electronic information. The Health Story, HL7, IHE Consolidation project is making great strides towards the creation of interoperable standards for the exchange and use of health information which will allow us to have the structured and encoded clinical data that we need to support automated processes, while at the same time retaining the human-readable narrative information that is required for communication and understanding. I personally have always been a big believer in having my cake… and eating it too. 

If you have any questions about the slides or the presentation please let me know. I’d love to hear your thoughts and experiences!

Till next time,

4 Responses

  1. Lynn, your posts are always interesting and theoretical, but could you please enhance them by providing more industry examples of facilities that are actually deploying this technology and how they’re doing it? Speaking for one major provider in California, I can assure you the word hasn’t arrived here, and the last hospital system to retain acute care medical transcriptionists is about to lay them all off.

    • Hello Elisabeth: Please see the information at this link. We gave a couple of examples during a Health Story webinar and I think you would be interested. Also, we have some big announcements coming up that I can’t talk about yet – but stay tuned! http://www.healthstory.com/news/news.htm

      We will begin to see more activity on this front too I think because providers are coming to realize that they can’t get everything they wanted out of their EMR. We’re looking to enhance and to make the EMR more useful for physicians and other users of health care information and there has been a lot of interest.

      Thanks so much for your suggestion!

  2. Lynn;
    Good Afternoon! I have just recently found your blog – very informative!! I am thinking of taking a MT course starting this fall – after ready all your info, I am a little worried about this now . . . any suggestions for me.
    Thanks for your time!
    Lori (in Canada)

    • Hello! thank you for your comment! How fun to know we are reaching an international audience! 🙂

      Please do not let my concerns cause you to change your mind about possibly entering the field. I absolutely believe that medical transcription still plays an extremely important role in the creation of clinical documentation. Yes, the industry has its issues (which one does not?) which I try to address here, and any type of career-related decision needs to be made after exploration and research, but transcription is a valuable profession.

      Also, I quite admittedly do not know much about the transcription market in Canada. There may be some differences between transcription in the U.S. and in Canada which remove some of the concerns. I would explore the opportunities before making your decision and then make your decision based on that information.

      One word of caution – there are a number of forums available on the internet where it seems no one is welcome unless they are complaining. 🙂 Be careful about your sources. Check out AHDI at http://ahdionline.org/. They have a Facebook page too where you can ask questions of the audience and perhaps find someone who has good sources of information for you. http://www.facebook.com/AHDI.FB

      Good luck to you Lori!

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