Over the last few years, we have seen many clients implement or start planning the use of an EMR (Electronic Medical Record) in their facility. As we have seen, facilities treat the idea of physician data entry into the EMR differently. We have some clients who quite simply say “We’re switching to an EMR and it’s up to you, the physician or caregiver, to enter your patient notes and letters into the EMR. There will be no more transcription” to the other end of the spectrum “We’re switching to an EMR and you can choose whether you want to enter your own patient notes and letters into the EMR. If you don’t want to, you can continue to dictate and the transcriptionists will enter the data for you”.

For the most part, the second scenario is the most common with larger clinics and it’s mostly been to try and minimize resistance of switching to an EMR caused by the physicians or caregivers thinking they will be spending too much time on data entry versus seeing patients. Whether you see this as being an issue or not, there are advantages to using an EMR with a dictation system versus having the physicians or caregivers enter all of the patient notes and letters themselves.

First off, a big part of how willing a physician or caregiver will be to enter his or her own notes into the EMR depends on a few key things;
1. How easy is it for the physician to get where he or she needs to be within the EMR to enter the notes or create the letters. This varies from EMR to EMR
2. Can they create canned text (aka macros, templates, auto texts etc…) to help speed up their data entry
3. Are they prepared to spend enough time to ensure the data they enter is correct (i.e.: grammar, spelling, context)

Another part of how willing a physician will be to enter his or her own notes will be how good your transcription department is which is why point 3 was mentioned above. For every story we hear of a bad transcriptionist, we hear a dozen stories of how great other transcriptionists are. Many physicians and other caregivers rely on their transcription department to correct their grammar or format their reports or letters properly.

So, with all this said, how can Dictation, Transcription and Speech Recognition fit in the above equation? See Part 2 of this blog, which will be posted shortly, to see how some of our clients use Dictation, Transcription and Speech Recognition in conjunction their EMR to get the all-important patient information into the EMR.

Post By: +Ryan Gaudet