Blog | Wednesday, May 30, 2012

QD: News Every Day--EHRs driving dictation the way of the dodo

Physicians who dictate their notes appeared to have worse quality of care than physicians who used structured forms in an electronic health record (EHR), a study found.

Researchers conducted a randomized, controlled trial of a documentation-based clinical decision support system for coronary artery disease and diabetes. Physicians were at one of 10 primary care practices that were part of a larger network in eastern Massachusetts. Researchers measured the quality of care of physicians who used dictation, structured documentation, and free text for their notes.

The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after a primary care visits. Results appeared at the Journal of the American Medical Informatics Association.

During the 9-month study period, 7,000 coronary artery disease and diabetes patients made 18,569 visits to 234 primary care physicians. For these visits, 20 (9%) of doctors predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes.

Quality of care appeared significantly worse for those who dictated notes than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam). Quality of care was better for those who used structured documentation for three measures (blood pressure documentation, body-mass index documentation, and diabetic foot exam). Those who used free text documentation had a higher quality of care for one measure (influenza vaccination). There was no measure for which those who dictated notes had a higher quality of care than physicians using the other two documentation styles.

Lead author Jeffery A. Linder, MD, FACP, and colleagues wrote, "Physicians who used the EHR more intensively for documentation could have paid more attention to necessary items that were missing from coded fields. In addition, physicians interacting with the EHR had greater potential to see and respond to clinical decision support before, during, or after the patient visit, some of which was relevant to CAD/DM [coronary artery disease and diabetes] documentation and care.

"Notes could be dictated without interacting with or even necessarily looking at the EHR," the study continued. "Dictations were uploaded to the EHR as unstructured, free text. In addition, dictation built in a documentation delay with unstructured information reaching the chart potentially days after the patient visit, when an opportunity to take action may have passed."