Room for improvement in EHR dictation methods, says study

According to a new study published in the Journal of the American Medical Informatics Association (JAMIA), physicians who dictate their notes prior to entering them into electronic health records (EHRs) have lower quality of care scores than those who enter information directly.

More than 7,000 patient visits to 234 physicians were analyzed by researchers at Brigham and Women’s Hospital in Boston. Key findings of the study suggest that clinicians who entered patient notes directly into medical informatics systems reported higher levels of patient care than physicians who dictated or transcribed their notes beforehand.

Researchers claim doctors who entered information into clinical informatics networks directly were less likely to miss necessary steps in patient care than those who favored dictation. In addition, doctors who enter patient notes directly made use of advanced medical informatics functionality such as clinical decision support tools, which further improved standards of care.

Mark Anderson, a healthcare IT consultant based in Montgomery, Texas, told Information Week that speed and simplicity were two possible reasons that many physicians continue to dictate their notes as opposed to entering them directly into medical informatics networks.

“They just want to get the note done,” Anderson said. “Physicians need lab results, pharmacy, nursing notes, social history, and so on. The doctors don’t put any of that in. The results come from the lab. They may do electronic prescribing – but that’s not notes, it’s orders. Compared to the amount of time required to enter structured data, it’s much quicker to dictate, and it’s probably two or three times as quick to type it in.”

However, while the use of structured documentation entry methods may increase the quality of patient care, many physicians using this method expressed dissatisfaction with the process.

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