JAMIA: Dictated EHR documentation low on quality totem pole
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Jeffrey A. Linder, PhD, division of general medicine and primary care at Brigham and Women’s Hospital in Boston, and colleagues conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network to measure the quality of care of physicians who used dictation, structured documentation and free text EHR documentation styles.
The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits from March to August 2007. During the research period, 7,000 coronary artery disease and diabetes patients made 18,569 visits to 234 primary care physicians of whom 9 percent predominantly dictated their notes, 29 percent predominantly used structured documentation and 62 percent predominantly typed free text notes.
Based on 188,554 notes, dictators dictated 67 percent of their notes on average, used structured documentation 4 percent of the time and used free text 32 percent of the time. Structured documenters dictated less than 1 percent of their notes, used structured documentation for 54 percent and used free text for 46 percent. Free text documenters dictated less than 1 percent of their notes, used structured documentation for 4 percent and used free text for 96 percent.
In multivariable modeling adjusted for clustering by patient and physician, quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation and diabetic eye exam); better for structured documenters for three measures (blood pressure documentation, body mass index documentation and diabetic foot exam); and better for free text documenters on one measure (influenza vaccination).
There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles.
“None of the three methods of documentation, by themselves, would fulfill the quality measures,” the authors wrote. “All three result in text within clinic notes. So, why might structured documentation have been associated with improved quality of care? Physicians who used the EHR more intensively for documentation could have paid more attention to necessary items that were missing from coded fields.”
While Linder et al stated it might appear obvious that physicians who use a more EHR-intensive documentation style would have better EHR-documented quality of care, they warned it is not a foregone conclusion. “Physicians who dictate could potentially have more time with their patients, time to review quality reports and time to direct practice staff to enter structured data. Until large scale natural language processing (NLP) can produce structured data from dictated and free text reports, structured data entry will be an essential input to both clinical decision support and increasingly detailed quality measurement.”
Even dictation with advanced NLP may not be ideal because it would limit physicians' interaction with the EHR and clinical decision support, they wrote.
“Whatever dictation style physicians use, practices need systems to ensure that critical coded information is captured and deficits in quality are addressed,” the authors concluded. “Potential solutions include increasing the useability of structured documentation systems so they are more appealing to physicians, improving NLP and other technologies to pull structured and coded data out of free text or dictated notes, and better use of affiliated staff, such as medical assistants or nurses, to enter critical coded data.”