Medical Records Quality – Dictation Comes In Last for Doctors

Posted by Dike Drummond MD

medical records quality doctor dictation worst optMedical Records Quality Worst with Physician Dictation

As I work with over stressed and burned out doctors … one of the most common causes of frustration is the documentation of medical records. It does not matter what system is used, most doctors see their medical records system as a drain and wast of time.

One of the laments I commonly here is “If only they would let me dictate my chart notes like we used to do !”

Here is a very interesting bit of data that suggests dictation, though it may be an easier way of creating your medical records than having to learn your EMR algorithms … may result in inferior patient care quality.

A new study  reported in the Journal of the American Medical Informatics Association looked at the best way to produce a quality set of Electronic Medical Records.

Brigham and Women’s Hospital researchers partnered with colleagues at other organizations to study

  • 18,569 patient visits for 7,000 patients
  • to 234 primary care physicians
  • The study measured 15 EHR-based coronary artery disease and diabetes measures assessed within 30 days of a patient visit

=> 9% of the physicians dictated their notes by telephone, which were transcribed and uploaded into the EHR
=> 29% of them used structured documentation in the EHRs, such as templates
=> 62% typed their notes in free text into the EHRs

physician leadership dirty little secret

Here’s what this medical records quality Study Found:

“In multivariable modeling adjusted for clustering by patient and physician,

Quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam);

Better for structured documenters for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam);

Better for free text documenters on one measure (influenza vaccination).

There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles.

Conclusions EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.”

It would appear that the structure of the record or the physical act of typing rather than dictating lead to a measurable and significant increase in the quality of the medical records produced. My advice for practicing physicians remains the same …

Invest time in learning how to be a “Power User” of your chosen electronic medical records system

Embrace your electronic medical records charting interface rather than fight it. If you are in a larger practice, sit down with the known power users in your office and take some lessons. There will be a learning curve no matter what medical records system you use AND becoming fluid and skilled in the interface is now part of the modern physician’s job description.

Here is a link to this medical records quality study


Tags: Physician Coaching, EMR