Method of Clinical Documentation and its Relationship to Quality

by Dr Nick

So there was a lot of interest in the paper published in JAMIA

Method of electronic health record documentation and quality of primary care published on JAMI this month. A quick summary

They evaluated 18,569 primary care visits, 234 doctors in 2007-08

Note taking Breakdown
62% of free-text notes
29% structured documentation
9% mainly dictated their notes
Quality Measures
15 coronary artery disease and diabetes measures
assessed 30 days after visit
Quality of care was worse on 3 outcome measures for doctors who dictated notes
 anti platelet medication, tobacco use documentation (22% vs 36%) and diabetic eye exam


Their conclusion:

EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.

My Conclusions:

I don’t follow that logic – what they appeared to measure was the quality of the documentation not the quality of care? The measures are measures of documentation not of quality of care or clinical outcome.

It was not clear to me if that data might have been in the documents but was not identified (extracted) to if they reviewed all the documents and abstracted that data to determine if the data was missing or not. 

The study was carried out some time ago (2007 – 2008) – 4 years is an eternity in technology advancement. The iPhone was only launched in January 2007….look what that has done to the mobile world and telephones.

As I noted in my most recent VoiceoftheDoctor Radio Show with Dr Ruthann Litman, Dr Sidney Litman and Dr David Eibling it is the integration of solutions in a seamless way that will be successful and is measured by physician satisfaction. Turns out some doctors like dictating, some like using the keyboard and mouse, some like using speech recognition – and in the case study they are presented, some like to have a scribe/librarian/medical specialist do their keyboard interaction under their direction

The overall capture of quality elements was not great so we have not licked this problem yet (well not in 2008 anyway)

The ability to offer all methods but allow for the capture of these elements using technology is available today. This was nicely articulated in a piece just recently in HIT consultant in an interview with Carina Edwards – Understanding Clinical Language Understanding.  

The Reliant Medical Group (formerly the Fallon Clinic) did a study presented at HIMSS in 2010 comparing quality of notes and showed an increase in the quality of notes with a hybrid approach of speech over pure EHR entry and dictation. In many respects I would suggest as similar study and results..just a different interpretation


I maintain that choice for clinicians is the key to success – offering them the right tool that fits their personal requirements and needs adn that includes all variations of documentation capture with NLP and Clinical Language Understanding to provide the bridge between narrative content and structured data essential for the intelligent management of patients and their care


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