Documenting a patient encounter

Technology should complement and improve clinical care, not impose extra burdens on already overloaded medical staff. A patient's computer records should promote seamless transfer of care from one clinical team to another. This is best accomplished by using a conversational or narrative format rather than chunks of information scattered around divergent screen pages.

The medical encounter consists of stories within stories and narratives are essential to a patient's episode of illness. An electronic patient record system should enable clinicians to capture narratives easily.

Our document imaging system accomplishes that task easily. Most physicians dictate a patient's encounter and have their dictation transcribed into written word. Our system captures the written narrative and seamlessly files it into the patient's electronic chart.

The problem with most electronic medical record systems

Data entry has always been a major obstacle to healthcare professionals' acceptance of electronic records. Most input makes use of structured data entry which is restrictive, and extracting this information from a narrative requires more work from the clinician. Furthermore, creating a standardized clinical set of terms and keeping them up to date is resource intensive.

Most benefits of computer-based records rely on structured, coded data, not free text, but clinicians value the ability of flowing prose to paint an evocative clinical picture. Worse, the codes installed with software may constrain clinical language.

The ideal electronic records system should allow the clinician to input narratives effortlessly using handwriting and sketches as well as speech input. The easiest way to enter data into an electronic records system is to use speech, followed by handwriting and then by typing.

Speech is easy for data entry. Speech is natural - we know how to speak before we know how to read and write. Speech is also efficient - most people can speak about five times faster than they can type and probably ten times faster than they can write. And speech is flexible - we don't have to touch or see anything to carry on a conversation.

The fastest method for data entry is speech input, but the quickest way to assimilate information is reading structured text. It is quicker to retrieve and assimilate information by reading and scanning than by listening to speech.

Our document imaging system allows you to create a narrative through dictation and then captures the transcribed document, just as it was dictated. Later that document can be printed or viewed on a computer screen to assimilate the information contained in the electronic document. In other words it allows you to continue to practice medicine the way that is most efficient to you and doesn't confine you to a computer programs structure.

The relatively fluid process of patient management often does not match the rigidity of most electronic health records systems. Medicine is far form a factual science, and patient management requires a tentative, evolving reinterpretation of previous data in the light of new information. When new insights are gained, you can easily adapt your new findings into the management of a patient's care.

A look into the future

Speech recognition software is making great strides and within ten years will be a staple in most medical practices. It eliminates the need for human transcription and retains the freedom of using a narrative to document a patient's clinical visit. And, as we pointed out earlier in this document, speech is the fastest way to do data entry.

This emerging technology will nullify one of the largest benefits of an EMR system and may even render current application based EMR systems obsolete. By creating a narrative to document the patients visit, converting the sound file to typed text that is easily read, the ultimate electronic patient record is created. The only piece of the puzzle missing is the ability to manage the patient's electronic records.

Managing electronic documents is easily accomplished with our document imaging system. Documents need not be printed to paper and then scanned into the system, but rather can be acquired by the system in an electronic format that doesn't allow the document to be altered.

The pace of modern practice dictates the use of technology, but the lack of direct clinical input in the development and procurement of information technology has been cited as a major factor in the failure of many clinical information systems. Our document imaging system was designed with significant input from a physician. The result has been a document imaging system that is best suited for the unique makeup of a private medical practice.