Documenting the Patient Encounter
without the Data Entry Bottleneck
by James M. Maisel, M.D.,
Chairman, ZyDoc Medical Transcription
Dictation and transcription have remained the predominant mode of medical documentation for the past several decades. The clear advantages of dictation over alternative means of documenting medical records account for its enduring popularity.
All physicians learn how to dictate early in their training, because it allows unimpeded flow of thought for creation of a detailed, granular record. Nothing is faster than speech. Dictation of a comprehensive detailed encounter typically produces efficient documentation within 2 minutes.
Handwriting, normally at 20 words per minute, is slow and has legibility problems. A 2006 report from the National Academies of Science’s Institute of Medicine shockingly concluded that doctors’ sloppy handwriting kills more than 7,000 people annually. Legibility becomes especially important when groups share records and patient care.
Direct data entry is not the answer. Clicking and navigating through picklists is very tedious and takes more than 10 minutes per encounter. Very few people can type 80 words per minute and they have to be tied to a keyboard. Dictation can be done anytime, from anywhere, using a phone or a handheld digital recorder. Typical dictation rates are 180 words per minute, 9 times faster than handwriting. This is the fastest, most detailed method of data capture for documenting a patient’s record, and is used by virtually all high-volume physicians. Saving even half a minute per patient encounter per day allows physicians to increase the daily number of encounters, or to finish earlier. One of the top reasons for failure of EMR adoption has been the data entry bottleneck. To increase user acceptance, many EMR companies are now upgrading their products to include an integrated dictation solution.
Dictating for transcription does not require any substantial investment in training, education, changes in culture, or physician behavior. Proponents of standalone EMRs and other data capture methodologies point to the cost of transcription, up to several dollars per document, but ignore the 10-minute productivity loss that may cost $100 per encounter. Transcription costs, however, are more than offset by increases in productivity, improved legibility, and higher billing charges as a result of more accurate coding.
Dictation and transcription provide the basis for a comprehensive medical record that other members of the healthcare team can share. With modern transcription systems, the audio dictation can immediately be made available to other physicians. Transcription turnaround times can be expedited to several hours when necessary.
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Dr. Maisel, Chairman of ZyDoc Medical Transcription, completed his retina training at The New York Hospital-Cornell Medical Center as a Dyson Foundation vitreoretinal fellow. In 1993, he helped develop one of the first prototype multimedia EMRs that was purchased by the Department of Defense. In medical informatics, he served as President of HOST (Healthcare Open Standards and Trials), has participated in many industry and standards development efforts, and is a frequent lecturer.
Dr. Maisel has a unique perspective in applying technology as a practicing vitreoretinal and laser surgeon for over 20 years. His practice with the Retina Group of New York serves as a showcase utilizing ZyDoc technology and transcription integrated with best-of-breed cutting-edge medical informatics solutions in a production environment that addresses the complex challenges faced by medical practices in the 21st century.
