Dictation Markers in EMRs

Clinical Documentation Flexibility with Epic and Allscripts

The tried and true process of clinical documentation via physician dictation and corresponding transcription by talented medical language specialists has been a staple of US healthcare providers. Technology, including web-based systems, HL7 interfaces and automatic speech recognition, has brought dramatic efficiencies to this process, yielding accurate clinical documentation for advanced patient care. Turnaround times are now counted in hours and minutes instead of days and weeks. Many hospitals track turnaround times from physician dictation to enterprise-wide transcript access and consistently average under eight hours for a variety of worktypes that used to take 12, 24, 48 hours or longer.

As more and more healthcare facilities advance to an electronic medical record (EMR or EHR) the comfortable, proven process of clinical documentation via narrative notes is dramatically changed and may be eliminated entirely. Physicians at many hospitals and physician offices are now documenting each patient encounter within an electronic chart by checking boxes and typing in their own notes. The record is then instantly available online throughout the enterprise to speed discharges and advance the reimbursement cycle. While the pluses are many with an EMR, physician efficiency is often reduced as he or she thoroughly documents the patient encounter themselves at a keyboard. Not all medical disciplines lend themselves to check boxes and tree-type EMR methods. Physicians find that typing observations and medication lists takes longer than dictating as they have done for years. Frustration levels may increase as dictators attempt to convey detailed narrative at a keyboard instead of simply speaking their findings and impressions.

Fortunately, there is a best-of-both-worlds solution provided by some of the larger and better known EMRs such as Allscripts Enterprise and EpicCare InPatient. These EMRs include what is now called the ‘Dictation Marker’ feature to their systems. With Dictation Marker functionality, the physician works away inside the EMR system, yet is able to press a button and dictate at select spots instead of typing detailed findings or surgery details. Dictation markers allow what are typically short ‘snippets’ or ‘slices’ of dictation to be proficiently transcribed and automatically returned to a specific location within the electronic record. A physician may dictate one, two or three brief snippets within the documentation of one patient encounter as he or she completes the record. Alex Langsner, manager information systems at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, elaborates, “Because our physicians’ needs and preferences vary, we have adapted the Dictation Marker technology provided by our EMR vendor so that it works using both dictation via the telephone as well as via the computer workstation. Our physicians can choose which of those dictation technologies they’re most comfortable with and is most easily available, depending on their location. But we could only succeed at getting all this to work because our Dictation/Transcription System vendor, Arrendale, is as flexible, responsive, and skilled as they are. By partnering with Arrendale, we were able to enhance the standard capabilities of our EMR system - and everyone, especially the patients, benefit.”

From a technology perspective, the HL7 process with Dictation Markers is adapted to have the EMR send a file pair to the transcription platform. The file pair includes a wav file of the physician’s dictation and a data file, either an xml or text file format, linking patient and visit details to the dictation. The HL7 record then numbers each Dictation Marker voice file pair when it is initially sent from the EMR and that same Dictation Marker number accompanies the transcribed text, via HL7, when returned to the EMR from the transcription platform. The transcription platform, Arrendale’s TA+ in this case, stores the dictation marker in its database in a separate field from the job number’s location. HL7 expertise and EMR technology ensures that the transcribed text is inserted into the correct location of the patient’s electronic record, immediately accessible to other care givers in the organization. Depending on the EMR provider, the Dictation Number Marker may be referred to as a ‘serial number’ or ‘partial dictation number’.

While the file pairs are sent to a medical transcription service organization (MTSO) or hospital transcription department for processing, the physician frees up his or her time to spend with patients. The transcriptionist receiving a Dictation Marker voice file no longer hears the physician beginning with patient name, date of birth or account number. Instead, the transcriptionist gets started right away transcribing the physician’s thoughts such as medication plans or discharge instructions. The Dictation Marker voice file usually covers just one section of a traditional transcript such as History of Present Illness or Care Plan instead of the typical transcript components contained within a single voice file or ‘job’. When using Dictation Markers, the transcriptionist does not see patient name details and no longer needs to verify that the physician’s words are transcribed into the proper template worktype for a specific patient encounter. The overall quantity of transcribed lines can be reduced substantially, over fifty percent. Traditional headers and footers, identifying the patient, facility, worktype and physician are no longer part of the documentation process. Worktypes are reduced from many to a single Note template. “Our MTs have adapted easily to this new EMR workflow from EpicCare” comments Jeffrey Hubbard, president of Perry Johnson and Associates, a technology-savvy MTSO. “It’s important for us to have dictation marker know-how available for our customers as they transition to an EMR,” Jeffrey concludes. Transcription supervisor, Cecilia Zappa, from Archiivus, LLC that also uses TA+ software comments, “Archiivus has been using Dictation Markers for the past five years in conjunction with the Allscripts Enterprise EHR. This has proven to be an efficient way to detail the narrative portion of the medical record in a large clinic setting where there are many providers and varying dictation styles.”

In a Dictation Marker environment, everybody wins. The patient’s care is advanced with detailed, precise narrative notes contained in the electronic record which are quickly available. The physician is able to see and care for patients instead of being tied to a PC reducing the number of daily appointments or surgeries. The healthcare organization reduces expenses because the number of transcribed lines shrinks. Highly skilled transcriptionists contribute to the process as a second set of eyes making sure that medical and pharmaceutical language is accurate. As hospitals and physician practices assess EMRs and transcription platforms, it is important to include narrative note options in the evaluation process. MTSO partners must have advanced HL7 expertise and a software platform such as TA+ capable of handling the Dictation Marker process.

Arrendale Associates supplies comprehensive medical transcription solutions. Since 1989 Arrendale has developed and engineered healthcare software systems for dictation, workflow, speech recognition, transcription, electronic signature and document management. AAI began the A+Network Affiliation program in 2001 to provide integrated medical transcription outsourcing from A+Network MTSO partners. Hospitals, clinics and A+Network Transcription Affiliates benefit from AAI’s TA+ platform by reducing costs and improving healthcare with secure web access to transcribed patient documents. AAI customizes its products to meet the unique needs of each client with the engineering and interfacing proficiency required by today’s healthcare community. More information about the TA+ platform is available at www.aaita.com or by calling (800) 344-1323.


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