Electronic Health Records (EHRs) have replaced obsolete paper medical charts and records, and their ability to exchange health information electronically have helped organizations provide higher quality and safer care for patients. Notably, EHRs help providers better manage care for patients and provide better health care by providing accurate, up-to-date, and complete information about patients at the point of care and enabling quick access to patient records for more coordinated, efficient care. Other advantages include helping promote legible, complete documentation and accurate, streamlined coding and billing and improving patient and provider interaction and communication, as well as health care convenience. However, despite their numerous advantages, EHRs can create an overload of documentation and clerical responsibilities for physicians, placing an increased demand on physicians’ time and compromise efficiency. Medical dictation, transcription, and scribing services have become an increasingly popular solution to address this hindrance to quality of care. These documentation methods provide many benefits and potentially lower costs. This resource introduces different transcription, scribing, and dictation services, and reasons why health centers should consider using them to reduce the burden of EHR documentation.
The Challenge of Documenting Data and Medical Record Quality
Despite massive effort and investment in health information systems and technology, and many years of widespread availability, the full promised benefits of EHRs are far from fruition. In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act promised to provide more than $35 billion in incentives to promote and expand the adoption and use of EHRs. The adoption of EHRs is widespread; as of 2018 UDS reporting, more than 97% of health centers are using EHRs at all sites with all providers. However, significant barriers to their use remain, notably, physician frustrations and burnout related to the technology. Physicians report that the primary advantages of EHRs include improvements in documentation (63%) and collections (39%), improved clinical operations (34%), and improved patient satisfaction (32%).The negative impacts of EHRs are most apparent in patient encounters – physicians reported decreased face-to-face time with patients (70%) and decreased ability to see more patients (57%).
As administrative responsibilities increase, clinical documentation is often the first task to end up suffering. The EHR has created additional administrative burdens on providers such as the need to perform data entry while trying to engage with the patient during the health care visit. Providers have become frustrated and distracted with the documentation requirements, which further hinder connection and communication with the patient. The American Medical Association (AMA) and other groups note that physician burnout is a systemic problem requiring examination and improvements in the system-of-care delivery. Medical record production technologies may be the key to achieving the goal of creating better and timely medical records, while at the same time increasing cost effectiveness. Studies have shown that the utilization of services like medical scribes or voice recognition strengthened the patient and provider experience and is associated with lower rates of burnout. Furthermore, there is evidence that despite the higher overhead costs, additional documentation services can increase clinician productivity, lower billing errors, and foster work-life balance, retention, and wellness.
The obvious demand has driven innovators to provide a solution, and has manifested in scribing tools and resources with distinct modalities, with varying balances between using human capital and technology. This resource assess the strengths and weaknesses of these tools to provide guidance to health centers.
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