Partial Dictation within an EMR

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As healthcare facilities advance to an Electronic Medical Record (EMR) and Meaningful Use goals, clinical documentation via narrative notes may change dramatically.  Physicians at many hospitals and physician offices are now documenting each patient encounter within an electronic chart using a structured note format.  The record is then instantly available online throughout the enterprise to speed patient care and accelerate reimbursement.  While the EMR pluses are many, physician efficiency can be reduced when the physician is tied to a keyboard, typing or editing front-end speech recognition.  Not all medical disciplines lend themselves to physician entry of structured notes.   Most physicians prefer the speed and flexibility of traditional dictation over keyboard entry.
Many EMRs have solved this issue by adding the Partial Dictation feature to their system; what we consider the best-of-both-worlds solution.  Larger and better known EMRs such as Allscripts Enterprise and EpicCare InPatient have included the Partial Dictation, also known as dictation marker, feature for several years, but not all transcription platforms have the interface technology to handle Partial Dictation.  Within the EMR’s structured note, the physician is able to press a button on the keyboard and dictate at select spots to explain complex or unusual details.  Partial Dictation segments are typically short ‘snippets’ or ‘slices’ of dictation that will be transcribed and automatically returned to a specific location within the patient’s electronic record.  A physician may dictate one, two or three brief dictation markers within the documentation of one patient encounter as he or she completes the record.
From a technology perspective, the HL7 process with Partial Dictation is adapted to have the EMR send a file pair, a wav voice file and either a text or xml data file, to the transcription platform.  Since the file pairs are sent to a medical transcription service organization (MTSO) or hospital transcription department for processing, the physicians are free to return to their patients.  The transcriptionist receiving a Partial Dictation voice file no longer hears the physician beginning with patient name, account number or date of birth.  Instead, the MT transcribes the dictated details that pertain to just one section of a traditional transcript such as History of Present Illness or Care Plan rather than a complete, many-sectioned narrative.  Fine-tuned HL7 transactions make sure that the transcribed text is returned to the correct location within the note in addition to being returned to the correct visit record.
The overall quantity of transcribed lines is often reduced substantially.  “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.   In a Partial Dictation environment benefits include increased physician efficiency, reduced transcription outsourcing expenses and widely accessible, complete data for better patient care.  Transcription supervisor, Cecilia Zappa, from Archiivus, LLC 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.”
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