Use of dictation as a tool to decrease documentation errors in electronic health records

Abstract

Background: Use of Electronic Health Records is increasing. Copy-and-paste function is frequently used with higher rates of documentation errors. Studies to determine the nature of such errors are needed.Objectives: Determination of the effect of implementing a dictation system for completing notes on the quality of clinical documentation. We hypothesized that implementation of the dictation system for note writing would decrease the rate of errors in the progress notes as well as decrease the rate of copying and pasting. Design/Methods: A prospective interventional study in inpatient medical service for six months’ duration starting in July 2016. Resident physicians’ charts were reviewed by the attending physician on a daily basis. This study was done in a community based hospital affiliated to a university program. Residents’ physicians included Internal Medicine, Transitional year and Combined Internal Medicine Pediatrics residents. Charts reviewed for hospitalized patients. A total of 54 residents were offered a pre-intervention survey indicating their subjective use of copy/paste function. Response rate of 85.18%. Progress notes were reviewed on a daily basis for residents on their inpatient rotation. A total of 621 notes were reviewed. Results: Percentage of notes copied prior to the intervention was 92.73% which decreased to 49.71% post-intervention (RR of 0.54, 95% CI 0.48 0.60 Z statistic 11.005 with p-value <0.0001). Of the copied notes percentage of errors pre-intervention was 58% with no errors identified post-intervention (RR of 0.005, 95% CI 0.0003 0.0795 Z statistic 3.752 with p-value 0.0002). Most of the errors are from notes copied by the same author (85.8%). The most common documentation error was in the physical examination section. Conclusion: Implementing a dictation system eliminated documentation errors over our six months’ study. Further studies are needed to check long effects of using such systems on documentation errors

Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions

“…On the other hand, one of the disadvantages attributed to the EHR is that it allows "copy & paste" of previous records, duplicating information and perpetuating possible errors. This functionality has appeared in the literature related to saving time, increasing the efficiency of the process (Al Hadidi et al, 2017;Hartzband and Groopman, 2008;Heiman et al, 2014;Hirschtick, 2006;March et al, 2016;Shoolin et al, 2013). Transcriptions should be made in a conscious and responsible way by health professionals, taking advantage of the positive points for which "copy & paste" was created.…”

Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study

“…Notably, use of dictation technology has been associated with decreased use of Copy/Paste functionalities and decreased documentation errors. 28 Prior work has demonstrated a reduction in users of speech recognition technology after initial adoption to a more stable core set of users, corresponding with a "trough of disillusionment" in the adoption of new technologies. 29 This suggests that the learning curve associated with use of voice recognition technologies could be a focus for technological innovation and training.…”

Preferences to improve rounding efficiency amongst hospitalists: a survey analysis

“…Hospitalists were found to prefer in-person interactions with consults instead of over-the-phone consults or pages due to a higher level of productive communication, reducing turnaround time by up to 50% [17][18][19]. When documenting, dictating notes resulted in increased coherence due to an improvement in the quality of information due to a decrease in errors [20]. Multiple studies have shown that these systems increase satisfaction and efficiency positively, while decreasing overall monthly medical transcription cost [20,21].…”

“…When documenting, dictating notes resulted in increased coherence due to an improvement in the quality of information due to a decrease in errors [20]. Multiple studies have shown that these systems increase satisfaction and efficiency positively, while decreasing overall monthly medical transcription cost [20,21]. Another form of dictation is through a voice-recognition app on a smartphone that allows hospitalists to create notes quickly or record a voice file that can later be used as a progress note [22].…”