For the Record E-news Exclusive
EMR Data Entry: Point and Click vs. Transcription By Divan Da’ve The most critical part of any electronic medical record (EMR) is the method of data entry. The EMR is about aggregation of patient encounter data at the point of care to provide a complete, accurate, and timely view of patient information. An EMR is more than just a typed record of the patient encounter—it’s an extremely useful decision-support tool. The data can be entered into the EMR via any of the two general mechanisms: direct entry by the physician using point-and-click templates or transcription of dictated notes. Each data element to be inserted in the point-and-click template requires selection and navigation for capturing patient information. Transcribing patient encounters has been around for years. Each method has its advantages and disadvantages.
Point-and-Click Templates
Most EMR systems allow providers to generate clinical documentation by selecting variable terms from prestructured point-and-click templates. Users simply point and click to select appropriate choices from lists of choices to record a patient encounter. The end result would be a document that closely resembles a transcribed procedure note.
Advantages
- The templates are completely customizable.
- They provide consistent, complete, and accurate data.
- Notes for similar types of exams will appear to be standard and similar.
- Each click adds data elements to the database. Point-and-click systems create data that can be used to generate clinically useful reports, such as health maintenance reminders and disease management.
- One of the major advantages of template-based charting is the speed with which it can make the document available as a medical record. Since notes are created within the EMR, they are available immediately upon completion.
Disadvantages
- It takes more time—and definitely more concentration—for a physician to navigate through a large data set and create progress notes using point-and-click templates.
- Templates must be customized per the physician’s requirement.
- Customization can be inflexible and costly.
- Templates are well-accepted by only tech-savvy doctors.
- Any approach requiring direct data entry by the physician has generally failed because busy providers reject it altogether.
- Output from these templates is too canned and identical. It loses individuality for each patient.
- It is difficult for a provider to capture a complete patient encounter on a computer in front of a patient.
Transcription
Transcription has long been the standard for documenting patient encounters. It is more convenient for a provider compared with handwritten notes or electronic data entry. Transcription owns many advantages over point-and-click charting, but there are also a few disadvantages.
Advantages
- It corresponds with the physician's usual method of working. Dictation remains the most intuitive and least time-consuming means of data entry.
- Physicians can dictate anytime, anywhere using a PDA, dictaphone, or telephone at their convenience.
- Providers need not change the way they practice just to accommodate an EMR. An EMR can interact with transcription service so transcriptions can be attached directly into the patient’s EMR if such a feature is provided by the EMR vendor.
- It requires minimal training for physicians.
- It provides expressive power to describe the patient’s condition and other health-related events.
- Transcription provides for more efficient use of the doctor's time. Although the average transcribed report costs between $2 and $4, it can reduce the doctor's time spent on data entry. Considering the value of time, transcription is not a costly proposition.
Disadvantages
- Details of the exam can be easily forgotten and omitted while dictating if dictation is not captured immediately at the point of care.
- It cannot be queried for generating reports unless transcribed in preformatted templates.
- Transcribed reports are not immediately accessible. Physicians would normally have to wait for 12 to 24 hours for charts to be delivered; few vendors support short (two to four hours) turnaround times.
For a physician, an EMR that fits into his or her practice workflow would be invaluable. A competent EMR must have both a template-driven charting feature and the ability to interact with a transcription service. Because doctors are not unanimous on point-and-click charting or transcription, an EMR that features both would be efficient and cost-effective.
- Divan Da’ve is the CEO and founder of OmniMD™, a developer of HIPAA-compliant, Internet-based enterprise clinical solutions, located in Tarrytown, N.Y. |
