Electronic Health Record (EHR) data entry is a part of the job, but for most physicians it’s a chore. Not only does it take time away from your patients, it adds to the hours you spend in the office (or to the work hours you spend at home). Fortunately, many physicians have found ways to save time doing data entry.
One method is with the use of a medical scribe. They are professionals that document patient information into the EHR under the supervision of the physician. Team documentation, or “scribing”, frees physicians from writing notes, entering orders or referrals, and preparing prescriptions during the patient visit. This allows for more face time with patients, increased productivity, and efficiency, and increased revenue.
There are two different types of scribes to consider for your practice:
- An in-office scribe follows the physician through his or her work day and charts patient encounters in real time using the EHR. The American Medical Association has a CME module, Team Documentation: Improve Efficiency, Workflow, and Patient Care, for physicians who want to learn how documentation support help can have a positive practice impact. The free module provides an eight-step, solution-oriented program, as well as case studies, information on related Medicare payment issues, and an online calculator to estimate scribe savings.
- A virtual scribe listens to patient encounters through a secure HIPAA connection and documents as the physician interacts with each patient. After the exam, the physician reviews the patient’s chart with the scribe.
How to Find a Scribe:
Houston Community College Medical Scribe Program
The Medical Scribe is a six-month program approved by the American College of Medical Scribe Specialists (AMCSS) that prepares the individual for the field of medical scribe. Students will learn the fundamentals of the scribe field including medical terminology, anatomy and physiology, electronic health records, medical insurance, HIPAA as well as law and ethics for the health professions.
Voice (Speech) Recognition
Another option is voice recognition software - voice (speech) recognition technology is a possible solution for practices with EHR’s as demand for comprehensive, portable records grows, reimbursements shrink and quality measurement reporting requirements expand.
Voice recognition software comes in two broad forms: front-end and back-end. Front-end voice recognition software relies on a physician or nurse to activate the software, select the right input fields while dictating notes, review the notes, and then sign off on the document. This type of software seems to be more popular because it significantly reduces the role of the transcriptionist and recoups those expenses for the hospital or practice. However, a front-end process does require a physician or healthcare provider to review and sign off on the text, which can take longer. A back-end process relies on the software to convert speech directly into text without initial oversight from the physician who dictated the notes. The text is then filtered through a template that captures the requisite clinical information. At the end of the process, a transcriptionist reviews the form, but a physician or other provider usually still signs off on the completed document.
Voice recognition can be especially helpful if you’re not a proficient typist. It also can help by making the content of your notes more complete and specific, and it helps limit cut and paste within the medical record. Most EHR vendors have voice recognition software or make it available via a third-party vendor. Check with your vendor for more information on how to get set up.
Voice recognition is not without some challenges. Training the system to learn the practice or facility language model takes some time, and in the beginning may be less efficient than traditional dictation and transcription methods because the only way for the system to learn new vocabulary is to correct mistakes in motion, as they happen. A study done by the JAMA network found an error rate of 7.4% in speech recognition-generated clinical documents. The rate fell significantly after review by a medical transcriptionist, further still after clinician review. This shows the importance of manual editing and review, user training, quality assurance, and auditing.
Below are three market leaders in voice recognition platforms:
This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed. The Texas Medical Board (TMB) specifically states that all non-biographical populated fields, contained in a patient's electronic medical record, must contain accurate data and information pertaining to the patient based on actual findings, assessments, evaluations, diagnostics or assessments as documented by the physician.
CMS also states that the medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter and in 2013 the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning. For additional information from CMS regarding cloning please view the EHR Provider Fact Sheet.
It is important that physicians always review copied notes to make sure they’re accurate and relevant, otherwise there could be consequences including recoupment of payments if adequate documentation for billed codes is not provided, as well as action against the physician by the TMB.
The ERCI Institute has provided a two page handout with safe practice recommendations for copy and paste to help physicians benefit from the efficiencies of copy and pasting while avoiding potential drawbacks.
Below are some additional tips to avoid the negative consequences of cloning.