Time with the Doctor

Scientific American publish an article titled "Are Doctors getting slower or are patients getting sicker" that was based on a paper written and published in the Archives of Internal Medicine: Primary Care Visit Duration and Quality: Does Good Care Take Longer? Chen et al. Arch Intern Med.2009; 169: 1866-1872. (unfortunately subscription required). Apparently people are going to the doctor's office more often and for longer visits than 9 years ago. Whether this is because we need more medical attention or because there are more treatments available, the end result is the same as it is for imaging and radiology. Fewer resources spread over more work. In radiology the explosion of images (imagine the effect of single slice CT to 64 and more slices CT exams) has created less time to review per image for the number of radiologists available.

In medicine in general, if we the patient are consuming more time with more visits and for longer consultations - assuming the number of clinicians stays constant this should result in a decline in time per consultation. This represents a challenge in achieving the goals of modern healthcare

Two of the most pressing goals for the U.S. health care system are to deliver higher-quality care and to lower costs

Since most studies suggest that better care is linked to time spent with the clinicians - especially in complex cases. It turns out according to this study that

(they) found no evidence for the commonly held belief that physicians are spending less time with their patients or that quality of care has diminished

Time spent had increased from 18 minutes per consultation to 20.8 minutes. The investigators discount clinicians inefficiency as the reason for the increase:

Although it is possible that physicians are becoming less efficient over time, it is far more likely that visit duration has increased because it takes more resources or time to care for an older and sicker population

And while I think the complexity has increased in care delivery I think it is far more likely a combination of both (complexity of care and inefficiencies in the clinical care system) contributing to increase in time necessary to spend with the patient. Unfortunately much of this inefficiency is the new clinical systems and the complexity of capturing the information that has added significantly to the time required. No doubt we will see more studies that segment the time in more detail. In fact in some results published in this article in the Healthcare Ledger (Medical Transcription Relevance in the EHR Age - warning pdf) a study suggested that documentation time had quadrupled adding more than 110 minutes per day!

There is consensus on the value of clinical systems and digital information in particular the opportunity of providing more useful data at the time of the doctor-patient interaction. But it was clear from recent discussions that there is a divide in the way in which doctors and clinical staff should interact with these systems to capture and record information. There are those who view additional resources appropriate for assisting (Moving Transcription Back into the Hospital). And there are those that see a need for a change in approach and style to adapt to this process and incorporate into the doctor-patient interview. My own personal experiences support both answers. In some instances the interaction with the clinical system forces a change in the way doctors interact with patients and the process, work flow, methods and materials suit a new way of working. But in a recent experience at a clinician specialist's office (in this case a pulmonologist) it was very clear watching the interaction and in particular the flexibility and dynamic nature of the paper based note taking that any imposition of a digital system would not only slow the consultation to a grinding halt but would reduce the information captured dramatically. This is not to suggest that there is not (or will not be) a solution to this problem but the "standard" digital note capture system would be hopeless in this setting and be quickly rejected.

The comments to the article demonstrate some of the strong feelings - those of doctors overwhelmed with administrivia

Patients are NOT sicker and Doctors are slower, but only because of the inordinate amount of documentation required. My office note 40 years ago might have been: Sore throat-----Penicillin. We all knew what a sore throat was and that Penicillin was prescribed. In contrast Today's visit must include all vital signs, past history, a history of the presenting complaint, history of allergy, plus a rather extended physical exam, otherwise we do not get paid by the insurance companies or the Government. I used to see 50 or more patients a day and see them very well. Now, with all the rules I"m lucky to see 30 and am exhausted after doing so.
Dr. Michel Hirsch, FP, FAAFP (1967-present)
Donaldsonville, LA.

and the patients who feel they are getting less at a higher cost

I must live on another planet. Nurses have always performed all of the routine stuff like vital signs etc. I am 54 years old and have type 1 diabetes. I have never had a doctor spend more than 10 minutes with me, ever. It's usually 5 minutes and $70.

Both are right - doctors are required to do more in less time and patients are getting less. I like many others buy the vision of electronic medical records but perhaps not exactly as they exist today. The current large scale implementations and clinical systems struggle to account for the variations in specialties and their needs and while there is some element of best of breed approach many shy from this concept given the historical challenges of integration and intelligent sharing of information between systems from different providers. Things have improved - Healthstory (using HL7 CDA) as an example of an open standard that allows sharing of clinical data. This is a journey not a destination....and if there is a destination Ill bet that will be constantly changing! The challenge in the coming months and years will be guiding the beleaguered, over worked and underpaid clinicians through the maze of systems, their features and functions and helping them adapt their technology to their practice and vice versa.

How important is the digital record and if given the choice of doctors with and without what would you choose. For the practicing physicians that has an electronic medical record - is it a good or bad experience. For doctors still working in the paper world - can you see this changing or are your needs met currently and cannot be sustained in any of the digital models you've seen?

Moving Transcription Back Into the Hospital

What's old is new again......A recent article in USA Today (High-tech 'scribes' help transfer medical records into electronic form) highlighted the latest innovation in healthcare documentation - "High-Tech Scribes" who help "transfer medical records into electronic form. Is it just me or does that sound like something that is already going on in the electronic documentation industry with medical transcription and editing for the last 20+ years?

The challenge of capturing clinical documentation in digital format have remained the same and the continued struggle of adoption is highlighted by the poor adoption rate of electronic medical record systems

Today, only 1.5% of hospitals have a "comprehensive" electronic health record, and 8% have a basic version, according to Jha's March study in The New England Journal of Medicine. Most hospitals are intimidated by the cost, which can range from $20 million to $200 million.

Pretty poor given how long the industry has been working on this and despite the length of time still no clear exchange format or standard to facilitate the sharing of information

because there are no common standards for these records, doctors who do implement electronic charts may not be able to share them with a hospital across the street

But the value of digitizing medicine and implementing these systems has been clearly established and the terrifying level of errors that do occur as detailed in the landmark "To Err is Human - Building a Safer Health System" published in 2001 and many follow on reports and studies including he 2005 Health Affairs study that reported:

The country could eliminate 200,000 drug mistakes and save $1 billion a year if doctors in all hospitals entered their orders on computers

Despite these drivers we are still languishing in single digits of adoption and continue to struggle to roll out healthcare technology that effectively improves quality and safety without crushing efficiency and effectiveness of clinicians. So the University of Virginia Doctors elected to employ "scribes" to document the clinical encounter and these individuals such as:

Leiner, 22, a University of Virginia graduate who plans to apply to medical school

Who follow the doctors around and capture the clinical interaction on laptops. The consensus appears to be this will not catch on although a recent debate on the AMDIS list server offered some differing opinions that included some potential to reduce mistakes given the second set of eyes reviewing the documentation and the capture of the information real time with the patient. There is complexity in this approach made worse with gender conflicts (female patient and male scribe for example) but this approach appears to represent a modification of the current documentation process that uses dictation and transcription and perhaps offers some potential to free up clinicians to interact with patients rather than focusing on the clinical documentation and the electronic health record.

Moving the medical editor out of the bowels of the hospital just formalizes one of the well known methodologies in many transcription departments that attempts to link doctors to the same transcriptionists so they learn to "work together" (albeit remotely). This would make the bond stronger, the connection greater and the opportunity for error reduction using a trained and qualified "scribe" to document with the clinician. The medical editor is qualified, experienced and a highly knowledgeable resource that is currently disconnected from the clinical process.

Technology just becomes a facilitator in this process with speech understanding and speech recognition providing tools that can be used by one or both of the documentation team. The electronic medical record becomes integral to the documentation process. And although the real time aspects of alerts, evidence based medicine and the application of real time clinical knowledge to the interaction is still once removed from the physician the real time team documentation can provide direct access to the clinician through a combined approach to the capture and recording of the patient encounter.

How would you feel about a scribe being part of the clinician patient interaction - as the patient, as the clinicians or as the scribe?

Is Speech Recognition Ready for Prime Time - You Bet

In a posting on the American Medical News site titled: Is Speech Recognition Ready for Prime Time - You Bet Pamela Dolan refers to the history of speech recognition and how the technology was cited as one of the best things to hit healthcare - 10 years ago. In fact in 2005 I wrote an article for Health Management Technology Magazine (now available for purchase through Amazon): "Is Speech Recognition the Holy Grail":

Speech recognition technology has been lauded as the best thing to happen to healthcare technology since the advent of the computer, but is it really the Holy Grail? Speech recognition has the potential to overcome one of the most significant barriers to implementing a fully computerized medical record: direct capture of physician notes. Industry estimates from physicians and chief information officers at hospitals suggest that 50 percent of physicians will utilize speech recognition within five years. Coupled with this is the growing demand for medical transcriptionists, which is projected to grow faster than the average of all occupations through 2010

In pulling up the original article from my archive it made for interesting reading and while there were still problems with the technology in 2005 it had reached a tipping point and the summary at the end was pretty much on the money:

Speech recognition is good technology, but it is neither a panacea nor the Holy Grail. Speech recognition has been two years away for the last 10 years, but we may be approaching the Grail — finally.

Developments over the last several years have incrementally improved speech recognition systems to the point that some have intelligent speech interpretation—extracting the meaning, not just the literal translation of words—and producing high-quality documents with minimal human intervention. Further integration and embedding speech recognition with mainstream EMR solutions will allow for expedited capture of documentation as part of the clinical care process, offering clinicians a choice of methods to document creation. The last significant development in speech recognition technology was the recognition of continuous speech. The next big leap in this technology will be the merger of NLP and CSR to create natural language understanding. This development will take the technology to the next level and will offer a realistic opportunity to make speech recognition the de facto method of data capture for the medical community. The question is, When?

As the article from the American Medical News says:

"It (speech recognition) wasn't ready for prime time," Dr. Garber pointed out. "Now it is. No question"

But I disagree on the impediment to EMR usage that is linked ot the lack of discreet data. This is true with old style speech recognition - the process of converting the spoken word into text

The problem is when you talk into it, the data is not discrete ... it's still like a Word document

but not for speech understanding which is the the merger speech recognition and natural language understanding - available today. Already in use in many sites and delivering data in Healthstory CDA4CDT format.

So to answer the question - Is Speech Recognition Ready for Prime Time: You Bet!

So are you using it, what are your experiences or would you rather be entering data using forms and computer screens?

I Can't See My Patients Because I'm At A Screen Entering Data

As with so many services the world is getting flatter (per Thomas Friedman: The World is Flat - A Brief History of the Twenty-first Century) and medical services and in particular medical care is no exception. Everyone must run faster just to stay in place even the health care profession. We are seeing increasing interest and uptake of "Medical Tourism" (this term seems wrong to me - it reminds me of "Friendly Fire") and a recent posting on the Wharton Site on Health Economics: Bangkok's Bumrungrad Hospital: Expanding the Footprint of Offshore Health Care (Props to HISTalk). As with many of the offshore medical facility there are questions regarding safety and oversight (see this web site regarding Jim Goldberg's 23 year old son who died there and he is convinced there is a cover up and conspiracy).

That aside the interview with Mack Banner CEO of Bumrungrad makes for interesting reading especially when it comes to the implementation of their Electronic Medical Record system (in this case Microsoft's Amalga) and their move towards a totally digital hospital. This is interesting not least of all because Microsoft is exploring this vertical in another country and developing a solution that we will likely see being rolled out in this country once they have worked out all the issues and filled in feature/functionality gaps. But from a documentation standpoint as Kenneth Mays (the Hospital's Director of Marketing) points out:

We talk to our colleagues in the States and they're all facing the same challenge of getting doctors to enter things into computers. It's wonderful in theory. It makes your system more efficient. It makes it faster. It takes out a big source of errors. But it requires doctors to type in these things and it's not easy to get doctors to do that. It could also take something away from the doctor-patient interaction if the doctor has his head buried in a computer rather than looking at the patient and having a dialogue with the patient.... Hospitals, not just our hospital but I think hospitals everywhere, are facing this challenge.

This challenge is significant and one that remains unanswered in the limited roll out of EMR's. In fact a recent Washington Post article: "Electronic medical Records not seen as a cure-all" Alexi Msotrous makes the point that while everyone appears to agree that American Medicine needs to go digital (it is probably broader than that and I would suggest worldwide medicine needs to go Digital) the results are less than stellar and in some cases

suggest that computer systems can increase errors, add hours to doctors' workloads and compromise patient care

Yikes! The Senate Finance Committee has sent a letter to 10 major vendors demanding to know what steps have been taken to safe guard patient data - I expect the responses will be made public which should make for interesting reading. Meanwhile David Bluementhal rightly points out that

the critical question is whether, on balance, care is better than before and he (David Blumenthal) said. "I think the answer is yes"

I agree - we cannot continue the paper based record and we need data to feed these systems to make them useful. But to get this data in creates a data entry challenge that one physician said

I can't see my patients because I'm at a screen entering data

AND

his department found that physicians spent nearly five of every 10 hours on a computer, he said. "I sit down and log on to a computer 60 times every shift. Physician productivity and satisfaction have fallen off a cliff"

And my own daughter (as a patient) from her experience interacting with a physician office said "I wish the doctor would look at me as much as she looked at her computer" (See Doctor Please Look at Me not Your EMR).

The answer lies in using the current methodologies for capturing information - dictation, forms, and other tools that are blended to provide the easiest and most facile way to capture the data for clinicians. Making the data capture part of the clinical interaction without taking it over is essential. Clinicians talk faster than they can type - capturing that information and making this narrative tagged with semantically interoperable data that is usable by the EMR is possible today. Technology, standards and resources exist that allow for this today.

What would you rather be doing - typing at a screen or talking to your patients?

Information Overload in Healthcare

Physicians are drinking from fire hoses that are fed by the expanding number of systems and information sources. Dealing with this information explosion was the subject of a recent posting by KevinMD on his blog titled "How a wealth of information takes attention away from the patient" (it was a reposting from Abraham Verghese blog originally called "A Theory of Attentivity"). Despite a prime time for working inpatient coverage as residents and senior residents reach the end of their training year and are better and more experienced it has as he describes it, gotten more challenging for the mountain of data that:

...exists on each patient. It’s a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that

We add voluminous quantities of notes and data to a patient that represents the ever increasing haystack of patient data. IN fact as he quotes from a 1969 lecture:

What information consumes is rather obvious: it consumes the attention of its recipients

Or as he paraphrases TS Eliot with an excellent quote:

knowledge can get lost in information, just as wisdom can get lost in knowledge

Leading to a lack of attention to the patient. It's not just data as I highlighted in this post "Doctor Please Look at me not Your EMR" that stemmed from my daughter's visit to our local pediatricians office. While I understand the desire to push a "poverty of attention and agree that the computer should not rule the interaction as this hinders and in some cases destroys the clinical diagnostic process we do need to address this information problem.

The clinician interaction needs to be captured. Providing a point and click technology to capture that detailed process that he suggests to his student that demands:

getting as much as he can from listening to the patient, from sounding the body

Will never be captured in a drop down list or check box. This is the information in the narrative. But if we just load narrative it will provide little value as it just adds to the hay stack and clinicians will be relegated to turning pages of information in the eBook reader (better known as an EMR). For this information and knowledge to be useful it must be computer interpretable and usable by machines automatically. This is the strength that Healthstory format and structure brings. Allowing for the capture of the narrative but attaching codes and structure to that content that makes it useful.

The case is made - we need to keep the clinician patient interaction and preserve that content but it needs to be made useful. Filling in forms and selecting from drop down lists is not going to satisfy that need and worse may well limit the capture of rich detailed knowledge that is an essential part of that patient discovery process. Helping to bridge that gap is the Healthstory project that allows for both worlds to coexist happily.

Have you joined?

Doctor Please Look at Me not Your EMR

A recent personal experience with a pediatric office that I have been attending with my children for the last 7 years provides some valuable insight into the effect of an electronic medical record on a typical busy general pediatric clinical practice.

A little history - this practice has been servicing patients in our area for many years. Currently there are 7 physicians on staff and they have regular hours and see patients 6 out of 7 days providing on call coverage at all other times. They are great, my kids like them and my wife and I both love the practice. I have been to the practice and watched the impact of the implementation of an Electronic Medical Record (EMR) over the last 18 months. I was there shortly after they went live with their new system and watched as the clinicians struggled with a large unwieldy tablet using a combination of tablet and keyboard entry that clearly was uncomfortable and difficult for a physician who in previous visit had been highly efficient with a pen and paper based record.

The most recent visit was simple physical examination immunization and paper work for participation in sports programs. What should have been a brief efficient visit was not but it was my 10 year old who pretty much summed up the experience

She (the doctor) spent more time looking at her computer than at me

Practical medicine is about body language, facial expressions and interpreting more than just what someone says. The picture below dates back some years to an implementation of an EMR I was involved with in 1993 - the patient in the bed is ignored by the 5 doctors focused on the EMR screen in the corner:

When you ask a patient if there anything else that's bothering them you don't just listen to the answer but look at their face and the way they behave. There are clear indication if this patient is going to drop some significant additional piece of information on you with the classical line, often delivered as the patient is standing up and reaching for the door know

Oh and by the way doc..."insert interesting/relevant piece of clinical data"....thought that might be relevant"

It's a well known phenomena - part of our general make up that prevents from arriving at the doctors office for a "routine visit" and when first asked if you have any problems opening with

Yes, I have been bleeding rectally for the last 3 days, it's fresh blood

We all dread sharing what in our heart of hearts we know is bad news even though most know that early detection, treatment and dealing with problems is a much better strategy than putting our head in the sand:



To be clear I am not leveling criticism at our physicians - they are doing the best with the hand they have been dealt. Their perception of the EMR has changed over the course of this implementation. Prior to the implementation (which predates the economic crisis and the current rush towards a set of incentives currently linked, albeit with poor clarity, to implementing an EMR) they were not excited by the prospect of imposition of technology. Their decision was driven by their lead physicians drive towards modernization and the belief that current paper based systems were failing them in delivering the best possible care. They reviewed the choices and selected based on their needs. During the implementation the sentiment was very clear - everyone was fed up with the additional overhead required to cope with the new system and the huge change required in their day to day work flow and clinical practice.

Now many months on things have settled down. In the words of one of their physicians - they love the ready access to all the information on their patients when they are seeing them. For the most part the presentation of patient data is helpful and easily navigated..........but the capturing of this information is a burden and interferes with the clinicians/patient relationship.

Clinicians need to look at their patients, they need to interact with their patients and technology should not interfere with this essential component of the diagnostic process. Computers can be part of that interaction but currently in the vast majority of implementations they are a distraction and interfere. As my 10 year old said

Why is the doctor more interested in her PC than in me?

In fact in a recent exchange the story is even more disturbing with the roll out of these EMR's. A clinicians recently shared with me that his clinical interaction had changed since the new EMR system had been implemented. Since the system presented him with a series of choices to questions he would ask questions designed to elicit responses that were featured in the list. If he thought a question might elicit a response that was not featured in the list of choices available he would avoid that question since documenting the response was a time costly exercise.

Dictation has long been tainted as a problem not a solution....but dictation has been the mainstay of capturing clinical information. We moved from hand written notes to dictation and transcription as the volume of information increased. It made sense because off loading the heavy lifting of creating a typed legible note was more efficiently done by someone who specialized in that process and was more cost effective than asking a clinicians to spend more time documenting and less time seeing patients.

Despite the bad rap dictation and transcription is the mainstay of clinical information today - 60% of the data we have on patients is generated by dictation and transcription. Of the remaining 40% the vast majority of this data comes from automated clinical systems including laboratory and imaging systems that generate data - not clinicians who currently generate somewhere in the region of 3-5% of this information input into EMR's today.

But to satisfy the informational needs of the EMR we need the clinical data. This is possible today and the technology is available to make the process of dictation and transcription not only more efficient and cost effective but generating the data necessary to fill the information void in the EMR's. Instead of just accepting the concept that physicians should become data entry clerks ask how you can use existing technology and services to allow doctors to focus on their patients not on an inanimate piece of technology

I'll leave it to my 10 year old to sum it up

I wish she (the doctor) would look at me not her computer

How have your experiences been in any recent visits to your doctors office. Do they have clinical systems and do they interfere with your relationship with your doctor(s)? Let me know - I'll publish any stories people are willing to share

Digital Medicine Not Fulfilling Promises

The electronic medical record and the digitization of the health care system is entering more main stream media and coverage as evidenced by the article in Business week - "The Dubious Promise of Digital Medicine". As they put it the companies are:

in a stimulus-fueled frenzy, are piling into the business

Neal Patterson from Cerner is quoted likening this to the

19th century land rush that opened his native Oklahoma to homesteaders

If that analogy is correct then much of the activity is individuals and companies tuned to their favorite radio station WIFM...What's in it For Me? There are some interesting quotes including the suggestion from GE that they will "Leapfrog the competition" by not only replacing paper but "guiding doctors to the best, least-costly treatment". Now this is an interesting concept tied to Evidence Based Medicine (EBM) that has been around for centuries dating back even to Greece but has more recently attracted attention given the greater availability of data and the tools to process it. But as the piece highlights this rare consensus in Washington conceals the

checkered history of computerized medical files and (is) drowning out legitimate questions about their effectiveness. Cerner, based in Kansas City, Mo., and other industry leaders are pushing expensive systems with serious shortcomings, some doctors say. The high cost and questionable quality of products currently on the market are important reasons why barely 1 in 50 hospitals has a comprehensive electronic records system, according to a study published in March in the New England Journal of Medicine. Only 17% of physicians use any type of electronic records

In fact the 17% probably over states the actual usage as other reports suggest that while 17% of clinicians have purchased these systems there is a further gap in actual use bringing this down to a lower 7-9% in actual use.

In fact as David Kibbe points out

"Most big health IT projects have been clear disasters. This [digital push] is a microcosm for health-care reform....Will the narrow special interests win out over the public good?"

And nowhere has the challenge and in particular the failures been more apparent than in the UK's National Health Service (NHS) that has spent billions on the NPfIT program but has little to show for it.

But the attraction of large sums of money are hard to avoid, especially in the current economic climate and Allscripts CEO Glen Tullman like many, but perhaps with better access given his established relationship with President Obama, are vying for their share of the cash. McKesson have a slew of lobbyists to push their agenda and "building on existing technologies". Epic inevitably promotes the one system from one vendor with the corresponding price tag.

But implementation of these systems remains a challenge and the paper from 2005 in the Journal of the American Medical Association: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors (abstract here - full article requires subscription) linked errors not to fatigue but to the order entry system. Many subsequent studies support this and even suggest that once the error is introduced these systems have a tremendous effect on perpetuating and proliferating these errors into more health records. The most recent article from the New England Journal of Medicine hammers home the point on the adoption of these systems - "Use of Electronic Records in US Hospitals" (it's available here in full as a pdf) and reports that 1.5% of hospitals have a comprehensive EMR!

So where is this all going - uphill but with multiple interested and vested parties pushing. Part of the push has to come from the users and making these systems intuitive and easy to navigate should be a basic requirement. Requiring days or weeks of training suggests design problems in my mind. Creating interfaces that engineers like does not necessarily translate into a busy clinical setting. Usability, data capture methods and tools and above all workflow optimization that fits into our current future clinical practice will be critical. Just implementing the technology never delivered the value and it has been this historical method that we must recover from and show a smarter more user friendly system.

Anyone should be able to navigate and use an EHR, clinical knowledge resources and these healthcare systems but using them for greatest effect will require more understanding on the part of our current clinicians and support from the plethora of ancillary services and staff who contribute to the functioning healthcare delivery system. To borrow from one of my favorite innovative and error free industries - the airline industry: It is the whole team from design, construction, build, maintenance and ongoing support of airlines that makes the captain do a fantastic job. Take Capt Sully Sullenberger - his actions were truly awe inspiring but without everything around him doing what it was supposed to do and all the hours of training and support he received the outcome might have been very different. As a true hero and consummate professional while accepting praise he has been quick to credit others.

Healthcare is similar and in the old adage - "there is no I in team". We must all do our part in enabling the delivery of high quality healthcare - EMR's and Healthcare IT is one part of that which we do need to get right.

Telling the Full Story

For the Record magazine did an excellent front page cover story on the Health Story project "Telling the Full Story". With less than 3% of the typical patient record composed of direct clinician input and somewhere in the region of 60% of clinical data coming from transcribed documents we need to find a way to capture and utilize this information to feed the data hungry EMR.

The Healthstory project represents that leap across the chasm. The opportunity to bridge the divide between the human readable and essential detailed free form narrative and the data elements necessary to drive the the EMR systems and automated tools available today but struggling to work as they sit starved of discreet structured, encoded clinically actionable data. As part of this initiative is the recognition that transcription and medical editors are a value added service bringing extensive knowledge, skills and data analysis skills to bear on the over burden documentation industry. As Liora Alschuler points out:

for a number of years, the “narrative” has been the EMR’s enemy, a relationship that the Health Story Project aims to reverse. “If you look at even the most sophisticated IT environments in healthcare, they still need this because their EMR does not eliminate the narrative form,”

Changing this perception of the narrative as the enemy and embracing the rich capacity of expression possible in narrative language is an essential first step. With the inclusion of narrative not just alongside but linked to the structured encoded clinical data creates meaningful clinical documents "that handle structured data and natural language narratives with equal ease". Providing both the computer and the clinicians with information suited to their needs.

“Data is structured to support rich links between clinical documents and electronic health records. That makes it easy to share information across provider and computer system boundaries while still retaining the essential human-readable, detailed narrative in one document.”

There was also other recent coverage including this piece in the JAHIMA April edition (pdf copy here or online here). If you don't know what it is or what is means to your organization you should.

If you are going to be at the MTIA conference this week - come along and find out more on Thursday April 23 at 7:30 - 8:15 (warning pdf). If not take the time to review the standards the "Shovel Ready" nature of the project, the benefits and the membership options)

The project has momentum and participation and needs your support. We should all be insisting on receiving the full story. If not

• press 1 to fill in all your information again at yet another clinical office,
• press 2 if you are fed up filling in forms and complete them half heartedly despite the fact that information is critical background to help your clinician make diagnostic and decision
• press 3 to have your blood work and x-rays redone since the information is not available to the one of multiple clinicians you visit each year
• Press 4 To skip a question since it does not have an suitable answer in the list of choices
• Press 5 To hear these choices, again and again and again

I know I want the full story and have been collecting mine for years.....are you?

Reinvestment is not Just About Technology

There is lots of excitement or even frenzy over the wave of investment coming down the pipe towards healthcare technology but in this piece on the Huffington Post: Workforce Development Essential to Obama's Health Care IT Initiative Julian Alssid and Jonathan Leviss are quick to point out that there is an essential element that must be included - that of Human Capital. Healthcare is unique and transplanting technology from other industries is not a straightforward process

Hospitals are not banks, or insurance agencies, or hotels. Healthcare's unique workflows -- including many physicians and nurses sharing computers in a busy emergency room, the challenges of maintaining working hardware in an intensive care unit, and the vast realm of data accessed to care for a sick human being -- require novel technologies and processes that cannot be easily translated from other industries.

While I agree that some technologies have stalled many are being implemented and are delivering success today. Speech Recognition did suffer problems in noisy environments (that's why the early adopters of this technology are Radiologists who mostly work in quiet reading rooms). But newer Speech Understanding which is modelled on nature's success in speech understanding by not only using audio inputs but also getting information from the patent's previous history, demographics, prior reports and any other elements that will help in understanding what was said.

But that's not enough

Physicians, nurses, and other health care providers routinely learn new skills and adopt new technologies....What is missing, however, is a parallel training track for a sufficient workforce to develop, implement, manage, and support advanced information technologies in hospitals, doctors' offices, and other health care venues.

So providing the infrastructure is one thing but having the resources to support it is an essential part. This is especially true for the embattled medical transcription industry that has been fighting declining rates of pay as hospitals and healthcare providers continue to push for lower and lower line rates. All this is driven by the perception of the medical transcription is a cost, when in actual fact it is a value added service that frees up the clinical staff to focus on taking care of patients rather than the drudgery of data entry. There are lots of examples of systems trying to turn clinicians into data entry clerks and while there are instances where this methodology makes sense in many cases it does not. Technology will help (see above - Speech Understanding is moving speech into the 21st Century) but even with this technology there is still the requirement to provide support and expertise to facilitate the process of capturing information that is essential to the new age of data driven medicine. The Medical Transcriptionist is the knowledge worker who delivers the value add of helping turn clinical information into structured clinical data that includes the fine detail in the free form narrative that clinicians need and want to include while adding tagged structured data to deliver the full Healthstory for the patent's episode of care.

Computers Don't Have to Depersonalizes Medicine

The NY Times article this week; The Computer Will See You Now written by a pediatric physician complains that the electronic medical record has depersonalized her interaction.

HISTalk commented on it in his morning update and highlighted the complaints:

• using the computer in front of patients is intrusive
• standard questions must be asked in order even when they clearly don’t apply
• the doctor might swear in front of patients when the computer does something wrong
• computers lose context because doctors can’t underline, write bigger, or otherwise highlight something important

And I would add that because it gets printed out and is held in a computer it appears to carry more weight/validity.

As the author says:

The benefits (of the EMR) may be real, but we should not sacrifice too much for them

And the end result for her is

In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care

But the prescribed treatment of a hybrid using a tablet ignores most of the issues and concerns highlighted and forgets the relative difficulty of interacting with tablet or screen based technologies while facing and talking a patient. No doubt there are some circumstances where this does make sense but the key to success is the hybrid approach or blended model that does uses all the available methods and tools.

It is important to not turn our clinicians into data entry clerks and utilizing the finely honed and developed skills of the medical editor/transcriptionist to convert this audio into the data necessary to drive the EMR. Technology can assist and provide some efficiency to the process and specifically Speech Understanding can automate some of this process. But this method of capturing the voice is repeatedly dropped or forgotten in this discussion. There are circumstances where this technique may not apply (public forum in earshot of nosy eavesdroppers fro instance) but for circumstances where it does voice provides a ready and efficient method. Historically this created text that the EMR systems had difficulty using (they are essentially data driven repositories) but with the addition of tagged information that is linked to the narrative all held in the complete Healthstory we bridge the gap. Not only allowing for the inclusion of the fine detail that is essential and influences care but linked and part of this same material is tagged structured and encoded data that can feed the data hungry EMR.

Annoying Hard to Use Systems Won't Be Used

It is no real surprise to find that criminals are getting a pass because the police in Queensland Australia don't want to waste time using an expensive "time-consuming data entry system" that takes hours for jobs that used to take an hour.

The QPRIME (Queensland Police Records and Information Management Exchange) is supposed to reduce the burden and improve efficiencies but due to the complexity of navigation, officers are:

reluctant to make arrests and they're showing a lot more discretion in the arrests they make because QPRIME is so convoluted to navigate....minor street offenses, some traffic offenses and minor property matters were going unchallenged

Naturally the Queensland Police Service are standing by their $100 Million investment with the tired and worn out mantra

....the benefits of the QPRIME system into the future far outweigh short-term disaffection by some officers

It's the same in healthcare and the EMR systems being pushed onto the busy clinician today. In some cases they rebel and refuse to be stuck in a system that forces inefficiencies but in many cases find themselves turned into data entry clerks. I've said it before and I'll say it again - why is it Healthcare is the only industry that tries to turn our most highly skilled knowledgeable resources into data entry clerks?

Stop the madness, allow clinicians to capture information without creating a burden of data entry. Clinical documentation is supposed to support clinical care and capturing it should not be a burden that prevents adoption of essential healthcare support technology like the EMR. There is a swathe of clinical documentation specialists who spend their lives offering highly skilled review and editing services that free up the clinician to focus on patient care. They are not just a cost - in fact they offer a value add service that has been delivering grammatically correct, well structured and presented clinical reports for many years. Allow clinicians to capture the full Healthstory that contains both these elements and satisfies the clinical need and computer’s insatiable demand for structured data.

Otherwise patients, like the criminals in Queensland, will find that their symptoms may go unchecked or noticed as clinicians are unable to do both data entry and deliver high quality care.

If you are a patient watching your clinician attempting the nigh impossible feat of paying attention to you and your clinical condition while juggling a laptop, tablet or some other computer based data entry system, do him and yourself a favor. Insist you want the full Healthstory and let him know he can deliver that with the help of his friendly clinical documentation specialist/knoweldge worker without him having to do hunt and click through endless screens. And if you do tell him, let me know what he says and leave a comment here.

Healthstory - Providing Data to Healthcare Business Analytics

A recent posting by Laura Madsen on the b-eye-network site titled "The Impact of the Obama Healthcare Agenda on Business Intelligence" reviews the stimulus package and its potential effect on Healthcare Business intelligence and Analytics. As she points out the package has said they intend to invest in

“invest in proven strategies to reduce preventable medical errors.” First and foremost is wider adoption of electronic medical records (EMR)

There is little doubt that EMR's can contribute to improving medical errors but as Laura rightly points out this impact is limited as

the disadvantage is that much of the data is textual and therefore more difficult to analyze

And promoting the advantages of the data base centric solution that demands specific answers and fills in fields does produce "quantifiable data for analysis" but is very limiting to the physician, but more importantly is turning our most highly paid. knowledgeable expert, the clinician into a data entry clerk - as I have said before and was quoted here you don't find the CEO of Merrill Lynch entering stock data....!

So how do we satisfy this need while not limiting clinicians to the small boxes and multiple choice hunt and peck nightmare yet still satisfy the need for structured data to provide some of the value for applying business analytics to this burgeoning pile of data.

The answer is already here with the Healthstory Project that provides the perfect container to capture and hold the full story of the clinicians patient interaction. Satisfying the needs of the clinicians to capture the fine detail of the interaction but also fulfilling the data requirements for EMR's and Business Analytic systems. Healthstory has already created and published four technical guidelines for the

• Consultation Note
• History and Physical
• Operative Note
• Diagnostic Imaging Reports

and unlocks the valuable data from narrative documents enrich the flow of data into the electronic health record and creating interoperable clinical document repositories. The coalition is growing and you should expect to see these specifications becoming part of any requirements for clinical systems and documentation providers to be able to comply and both receive and send Clinical Document Architecture for Common Document Types (CDA4CDT) documents. Time to get on board.

Why Speech Recognition is no Longer Sufficient

Speech recognition has been around for over 30 years and part of our consciousness since the mid 1960’s but it is only in the last 3-4 years that we have see the technology really start to deliver some value to the much beleaguered and over worked clinician. There are innumerable studies that demonstrate the savings linked to the efficiencies possible with faster report turnaround. Unfortunately producing more reports faster is not always the best answer and oftentimes this is simply making the patient information haystack larger. This tsunami of data is overwhelming even the best organized clinicians and many are struggling to keep up with this alongside the explosion of diagnostic and treatment choices. Keeping up with the medical knowledge is a full time job if anyone had the time – but they don’t.

Clinicians want to give great care - that's a universal maxim for the profession and anything that enables or facilitates this will be successful. But that's not what has been going on with speech recognition which has not only required a change in behavior to enunciate in special ways, dictate commands, speak slowly and add punctuation and in the ultimate punishment requiring the highly skilled and time pressured expert to review and correct poorly drafted content. The output is a blob of text that cannot be read or interpreted by the electronic medical record (EMR) since it is not machine readable.

Innovation in speech recognition was last made in 1993 when continuous speech recognition was rolled out. Since then the technology has stagnated and while allowing clinicians to type with their tongue has provided some efficiencies and improvements, speech recognition has failed to address the underlying challenges facing clinicians today. So now we have reached this point what’s next?

It is the capture of structured clinical data that can automatically feed the EMR that is the real goal. Achieving this requires an alternative approach to speech recognition, not just recognizing the words but actually understanding the meaning and context. Comprehending normal human speech is not a word recognition process but speech understanding process that takes as input not just the phonemes or parts of words but the complete context of a conversation including the intonation, the subject matter and relevant prior information which is all applied to the complete conversation. It is this process that enables humans to exhibit the “cocktail effect” which allows us to listen in to more than one conversation at a time even though we are not fully participating in either. The added knowledge allows for inferring of missed words and understanding the content allows us to complete the picture producing a fully understood interpretation of the speech. Speech understanding is the next frontier of innovation in clinical documentation.

This content can be stored as part of the full story - the Healthstory that contains the computer interpretable data AND the fine detail in the narrative that is the essence of clinical insight, judgment and essential to the transmission and flow of useful clinical information between all the team members delivering care in our multi disciplinary model.

David Brailer Weighs in on Health Information Technology

David Brailer writes on the Healthaffairs site with guidance to the incoming President on key reforms to our health care systems. The pledge he refers to of $50 Billion does not appear to jive with the released "American Recovery Reinvestment Act of 2009" (pdf file) draft report that features $20 overall for healthcare + $4.1 billion for preventative health care but relative to the previous investments this is a significant program.

He highlights 4 key areas:

The chasm between the have and have not's - not of health care but of EMR's but rightly he says

We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care. “Pay for use” can fund the conversion of the health care system to digital records and ensure that we get the life-saving and money saving benefits they promise

I agree - just buying these expensive systems and funding them seems a flawed strategy and we will just end up with a bunch of unused EMR systems.

Second - the need to build a workforce to enable the digitization of health care - 50,000 people by his reckoning, of people who understand both clinical medicine and information technology. Already in short supply and years in the making. This is right on the money (and I say that with a certain sense of pride since I fall very clearly into this category having made this transition long before this was even a career path or specialization). It is bridging this divide with clear understanding of the issue and challenges faced in practicing day to day clinical medicine that will facilitate acceptance and success.

Third - Information sharing, which is a core fundamental but remains a significant challenge by virtue of the proprietary and protectionist nature to the health care vendors to date. This challenge has thawed and there are many initiatives that will move the industry towards real sharing of data. I certainly want to take my complete "Healthstory" with me wherever I go having just completed the valueless paper based forms for the umpteenth time in my daughters physicians office. There are others but Healthstory represents the complete picture with flexibility to allow participation at a wide range of levels and different detail that makes the adoption more likely. Not forcing or mandating specific data or fields may seem like we loose the data but pragmatic approaches that drive adoption quickly will succeed where highly regimented and overly demanding standards tend to fail in complex environments. So here's my pitch to the incoming Obama administration - mandate the Healthstory standard for capture, exchange and sharing of clinical data. The resistance will be minimal and the standard will allow all stake holders to participate quickly and effectively. Granularity of information will increase over time as the value of this increasingly detailed data is demonstrated with real world use cases - market forces at work.

Fourth - freeing up the clinicians to use the technology and to get paid for digital consultation remotely and facilitating telemedicine. While you are at it I suggest resolving the challenges faced over the practice of medicine in different states as detailed here in the sad case of a Colorado Doctor being prosecuted by California.

Health care reform will happen...it has to happen and there is an explosion of suggestions and ideas, but the above four make a great start and I concur with David Brailer on their importance and value in making these reforms a resounding success but lets make sure that the interoperability is a fundamental part of the equation.

Why Doctors Don't Like EMR's

Mr HISTalk is on the money in his latest blog

Doctors, like 99% of people, want to be consumers of information, not creators of it

Doctors want to give great care - that's a universal maxim for the profession and anything that enables or facilitates this will be successful and will get used. But that's not what has been going on:

The model of forcing doctors to share their thoughts through manual electronic documentation is fatally flawed. There is no industry … none … where someone with the education and time value of a physician is expected to peck on a computer, especially in front of a client who’s only going to get seven minutes of time (I’ve never seen a CIO typing meeting minutes into a PC, yet they’re often the ones beefing about computer-avoiding doctors).

and my personal favorite part of this piece - philosophic johad:

....trying to force those small business owners to use computers based on some kind of naive philosophic jihad against the inefficiency of paper-based recordkeeping

He is right "speech recognition" (or better yet the newer and more relevant speech understanding) is ready for prime time.....

Gathering the data should not be the focus - it should be a natural by product of the interaction and speech can help in achieving this. The real value comes with driving clinical information to support to decision making allowing clinicians to focus on the healthcare process

Magical Thinking in Implementing Healthcare IT

There was a great article published in the Health Affairs Journal by Carol Diamond from the Markle foundation - "Health Information technology: a few years of magical thinking" - abstract here the full text requires a subscription

The concept of magical thinking in this context was that implementers must resist the concept where this notion that

..isolated work on technology will transform our broken system...Another tempting and related notion suggests that a lack of technical standards is the main barrier to health IT adoption..

Given that as they state

...the literature on computerization, stretching back to the 1980s, is unambiguously clear on this point: computers are amplifiers. If you computerize an inefficient system, you will simply make it inefficient, faster. IT can contribute to improving care only when underlying system processes are transformed at the same time.

To be successful instead of joining the stampede of standard creations from the likes of Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT) which are increasing awareness in the public and helathcare industry but have not according to recent testimony by Sam Karp of the California HealthCare Foundation stated

"Not a single data element has been exchanged in real world health care systems using standards this process has developed or deployed."

The point being that standards are adopted and the process of standardization is incremental. The internet being a great case in point that was developed over severalyears and floated to users unfinished and lacking consistency to allow usr interaction and use to help refine and develop a standard that we all use on a daily basis

So taking this concept to the next level and looking at the 60% of healthcare notes that are simply free-form notes - providing simple easy access to essential parts of this information would be invaluable. And there lies the beauty of the of the CDA4CDT system allowign for the capture and sharing of this infomation wihtout the impostion of structure, coding or limitations of choices. Sections can be easily identified and shared in a meaningful way. At a high level in the first instance but in more detail as people explore and adopt this standard and actually use it. THis is a standard to use without the imposed and artifical limitations that normally accompany the typical narrow "ideal" standard that does not meet the test for real use and genuinely useful interoperability

Healthcare CIO's Grappling with EMR Adoption

SearchCIO online magazine ran an article on EMR adoption that made for interesting reading:

When patients, physicians and payers embrace the electronic health record (EHR), life will be different in pretty amazing ways.....For the first time, patients will be treated by a personal team of clinicians. When a new drug for hypertension comes on the market, all patients (not just Nobel laureates like James Watson) will be able to map their genotypes and phenotypes to that medication to determine if it's right for them. Hospitals will be held to the "perfect care" standard -- the elimination of all medical errors in instances of preventable harm.

Wow! But the problem is we are nowhere near the level of adoption necessary to achieve these kinds of advances and the barriers to adoption remain frustratingly present and challenging. Privacy, interoperability, liability issues and physician reimbursement are all main stays of resistance to the move towards wide scale adoption of the EMR. As expected there are some frightening stories to hammer home the point from an emergency room physician who estimated he treated 80,000 patients "with my own hands

...the thing that stuck out as he looked back on his career was how many times he was put in a position of "guessing over and over," "flying solo," in an information vacuum. In situations where people "die right in front of you," he said he often felt he was "one data element away" from stopping a patient from dying.

Needless to say there continues to be the naysayers who are convinced that physicians " know what they are doing; why do you want to tell them what to do" but in all this seem oblivious to the tsunami of knowledge rushing down the luge of clinical practice that is impossible to keep up with.

I agree with John Halamka

that the lives of primary care physicians -- snowed under by paperwork that does not require an M.D. but is required nonetheless, frustrated by prescribing a medication only to find out it's denied by the insurance company and terrified of making a mistake -- is sheer misery. He predicted they will welcome the help, and patients will be better off for it. As the system stands now, "all the medical students are becoming dermatologists," he said.

And it's easy to see why with the information overload with "medical literature published every month that is is more than a doctor could read in a year". Not to mention declining reimbursements and shattered dreams that litter the halls of our hallowed medical facilities. We need EMR's and EMRs need data to provide the decision support that an automated and optimized medical technology infrastructure can provide physicians in their daily practices. But all of this should not turn clinicians into data entry or data capture clerks - they are not good at this task and technology is available to facilitate this issue and provide clinicians with the tools to ease the burden and provide them with the necessary clinical decision support they want and need.

EMR Adoption and PHRs

Chilmark Research published a "PHR Market Report, Analysis and Trends" - the Executive Summary is available for free (with sharing of your details). In their blog commentary they make an relevant point

PHRs simply won’t go anywhere without data and arguably the best source of data is a physician EMR system. Unfortunately, the adoption of EMR is abysmal across the care continuum of providers sitting at somewhere around 15-20% depending on how you count it/who you believe.

And even if you believe the 15-20% penetration of this, the vast majority of the information in these systems comes from dictation and transcription and is stored as blobs of text. There is certainly some potential for the personal health records/systems to help drive the capture of more shareable data. There are problems of security and confidentiality but as they suggest I think the benefits will outweigh the risks in the near future, especially given the entry of Microsoft, Google, Intuit and Dossia (there is a piece of my British Heritage that feels this is not the best name choice - see here).

For both PHR's and EHR's to succeed the data has to be shareable.....easily. It has to be as easy as clicking on a link or plugging in a USB stick and selecting import. To see what this needs to look like you need look no further than Facebook which has rapid user adoption. Facebook has exploded onto the social networking scene by offering simple ways for sharing applications, data and tools between all the users.

The HL7 approved CDA format represents the way forward and the potential to bridge the divide between structured and unstructured content. CDA4CDT commenced the process in 2007 and has defined the formats for 4 document types so far and there are more to come. There are several presentations available here. With shareable formats data can be made available from PHRs to EHRs and vice versa. This will drive adoption in both systems.

Crisis on the Front Line of Health

The NY Times article today "Crisis of Care on the Front Line of Health" makes for interesting reading and also passes commentary on the often touted and argued issue of the uninsured. But the focus on primary care and specifically the comments

Finding doctors who know their patients well and who deliver informed
medical care with efficiency and empathy has become quite a challenge
in America

Feels harsh - I think what they mean is finding a physician who is still able to offer this level of service and survive mentally and financially is a challenge. The worrying trend is the declining number of medical students electing a career in internal medicine - given their debt load as they finally emerge from medical school it is inevitable that many will follow the money and choose specialties that are well compensated. Internal medicine specialists are:

the doctors who ask pertinent questions, about health and also
about life circumstances, and who listen carefully to how patients
answer.

But this process takes physician time and to maintain income means fitting more patients into the available clinic time. With the current anticipated average based on managed care reimbursement levels

"..you have only six to eight minutes per patient"

Which Dr. Byron M. Thomashow states "...you’re forced to concentrate on the acute problem and ignore all the
rest [of the conditions],”

So the idea that we can load up physicians with additional administrative burdens documenting in forms and finding items in lists seems counterintuitive. Whatever solution must take account of current workflow and existing efficient methods of data capture and incorporate those into the clinical process. Dictation is one of several methods in use today - as it stands it currently accounts for at least 60% of the input to the medical record. Capitalizing on this existing method and working this into the systems will add no additional time burden. By enabling the addition of meaningful clinical data with the free form narrative and storing this in one complete document in CDA format we satisfy the need for computer accessible information without burdening overstretched clinicians with additional processes

Transcription the WD-40 of Healthcare

WD-40 is renown as a solution for all sorts of problems (the list of 2000+ uses - pdf) - in a recent e-mail I received it was cited as follows:

You only need two tools in life WD-40 and duct tape. If it doesn't move and should use WD-40. If it shouldn't move and does use the Duct Tape

We have been hearing that transcription is the being replaced and will eventually disappear being replaced by direct data entry into Electronic Medical Records. But to borrow from a famous saying "the reports of the death of transcription have been greatly exaggerated". A fact hammered home in a recent presentation by L Gordon Moore, MD at the 2008 Scientific Assembly of American Academy of Family Physicians and reported in an article by Healthcare IT News "Beware of the EMR 'Ponzi' Scheme". Dr Moore did not mince his words:

When you put an EMR into a primary care practice, your life is hell for the next year

EMR's are essential to delivering high quality care. We need the support of technology to help deliver the highest possible quality of care. But the penetration of these solutions in the marketplace are a good indication that there are difficulties with these systems and implementations. On a a recent visit to an office with a newly installed EMR system I compared the experience to prior visits. The process of interacting with the screen (be it a tablet or desktop PC or some other mobile device) was very intrusive and difficult to manage while trying to interact with the patient. It is next to impossible to enter data on a screen while looking at the patient. So what I think Dr Moore is referring to is the difficulty of entering in clinical data to these systems - I bet he loves the ready access to all the patients clinical information but hates entering anything.

There are no easy answers and certainly not one answer to suit all situations but there is a reason that dictation by physicians and the transcription of this material has been an expanding industry that has insufficient resources to meet demand. The process works and has been the WD-40 for healthcare documentation for many years. The process has improved in efficiency moving from wax recording drums to digital recording systems and portable recording devices that include digital recording pens. We have added technology to speed up the transcription process counteracting the original design intention of the typewriter and the QWERTY Keyboard which was laid out in this format to separate out the most commonly used keys to slow typists down! Macros, auto correct, word expanders, speech recognition and most recently speech understanding. But through all these efficiencies the medical transcription or Clinical Documentation Specialist Knowledge Based worker remains a key contributor and an essential part of the process. They continue to be the WD-40 in the process of producing meaningful clinical documents to transmit clinical information to the ever growing participants of the healthcare team charged with taking care of patients. Clinicians will dictate their notes - its fast, efficient and cost effective when you consider the cost of the clinician. As Dr Leonard McCoy put it in Star Trek:



To grease the wheels of clinical communication, medical transcription and clinical documentation continues to evolve allowing for the free form narrative dictation but extracting the clinical data that the EMRs are hungry for. Fulfilling both needs requires the next generation of clinical documents using the HL7 CDA standard for Common Document Types (CDA4CDT). These documents support the flow of data from dictated clinical information to narrative documents and into structured, computer accessible records that EMRs can accept directly to support patient care with discreet clinical data.

However one word of caution on efficiencies that is best summarized by Dilbert - "...I have infinite capacity to do more work as long as you don't mind my quality approaches zero":