During our recent implementation of an electronic template-based physician documentation (Cerner’s PowerNote ED) combined with physician scribes, we realized that while our charting was data-rich and detailed, it needed something more to capture the “story” of the patient encounter. Multiple options were explored, including free-text typing to supplement the template chart, but ultimately we found this to be too slow and cumbersome. We also looked at the use of “macros” (pre-completed statements) to cover a variety of conditions and medical decision making thought processes for more basic encounter charts, but macros are not designed to capture the common twists-and-turns of a complex ED visit. Thirdly we reviewed dictation as an option, but it is costly and places the narrative in a separate document within the EMR.
Ultimately I found Dragon’s speech recognition software to be the most fitting complement to our PowerNote ED with scribes model. Dragon not only allows a detailed narrative to be added to the template-based chart, but it enables me to focus my attention on the patient rather than the computer terminal. Dragon speech recognition software serves as a highly accurate and efficient means for real-time clinical documentation without the need to wait for a human transcriptionist to finalize the chart. This makes the complete clinical story immediately available to all providers across the continuum of patient care, at a lower cost, and with greater convenience than other forms of documentation.
Reid F. Conant, MD is a board certified emergency physician and chief medical information officer for Tri-City Emergency Medical Group in Oceanside, California. Dr. Conant provides medical direction for Tri-City Medical Center’s clinical information system and electronic medical record, including computerized physician order entry (CPOE) applications. His efforts resulted in one of the most comprehensive ED CPOE order databanks in the country. He has spoken nationally on medical informatics and process improvement. Dr. Conant attended Jefferson Medical College in Philadelphia, PA. He completed his residency training in emergency medicine at Stanford University Medical Center.
