A core feature of all electronic health records is the necessity of data input into discrete fields in the chart. This is most frequently accomplished by a combination of typing the information that is needed and selecting, by clicking, the discrete information that is required, such as specific diagnoses and lab and radiology studies. The need to efficiently and effectively input a large amount of information has presented perhaps the greatest challenge of going digital for many physicians, particularly those over 40 years of age who do not type very well.
A number of innovative solutions are now available to address this issue, none perfect, and all offering alternatives to traditional means of documentation. We will briefly review three of these alternative methods, along with some thoughts about the advantages and disadvantages of each method. Let us also say that a challenge for all the methods we will discuss is the cost of the methods, and an advantage that all these assistive technologies offer is the ability for physicians to save time and lessen aggravation. Proponents of all strategies that charge money to save physicians time state that the time saved is equal to revenue earned seeing more patients, which in turn more than pays for the cost of the solution.
Transcription software, the most popular of which is Dragon, has been available for quite some time. This software can accurately transcribe the physician’s dictated notes into the appropriate section of the EHR. Many of the most popular EHRs now have the ability to have speech recognition fully integrated into the workflow of documentation of the EHR. The benefit of transcription software is that the physician directly determines what is going to be documented in the chart and retains complete control of the note. The disadvantage is that the physician still takes time organizing the note and inputting data.
To address the issue of the physician’s needing to take time to input information into the EHR, some practices have begun to use medical “scribes” in the form of a person who is in the room during the visit and is trained to write a note as the doctor sees the patient. The scribe will also order labs and x-rays as requested by the physician. An advantage of the scribe is that the physician can focus on the patient and does not need to navigate the EHR or worry about inputting data at all. In addition, feedback is usually given to the scribe on an ongoing basis so the scribe learns the preferences of the physician. The disadvantage is that the scribe is in the room during the visit, which can be awkward for patients, particularly if sensitive information is being shared about psychological problems, family planning, STDs, or any of many other issues that are routinely discussed at primary care office visits.
Finally, a California company, Augmedix, is trying to blend a 20th-century concept with 21st-century technology, seeing and paying attention to patients while doing electronic documentation. We want to disclose that we have no personal or financial interests in the company. Augmedix is essentially a scribe service with a modern twist. The physician wears a small head-mounted computer that includes a microphone, camera, and transparent display. This allows visual and auditory data from the patient visit to be transmitted to a scribe (a real, live human) located remotely in one of Augmedix’s data centers. The scribe is “logged in” to a copy of the physician’s electronic record and documents the visit in the appropriate place in the chart. This occurs in real time, so when the physician is finished seeing the patient, the note is complete and ready to be signed off. The benefit here is that there is no additional person in the room during the visit, yet just as when a scribe is in the room, the physician does not have to deal with negotiating the complexities of input into the EHR. In addition, through a feature the company calls “concierge service,” Augmedix scribes have the ability to display data to the physician upon request. For example, if the provider says “show me the blood pressure from our last visit” or “bring up Mrs. Smith’s x-ray results,” the scribe can send the requested information right to the tiny display on the headset. This allows the clinician to be “untethered” from the computer.
The concept raises a number of technical and philosophical questions. Foremost among these questions is that of privacy. Pelu Tran, president, CCO, and cofounder, explained that the technology is completely secure and compliant with all privacy laws. The data feeds transmitted through the headset are encrypted and are not permanently stored on any of Augmedix’s servers. Once the documentation is complete, the information is destroyed. HIPAA laws allow for this arrangement in the same way other transcription services are allowed. One disadvantage is likely to be cost, but Mr. Tran states that internal data show that a typical primary care physician can have about one to three additional patient visits per day using this tool and that the added revenue from seeing more patients should cover the cost of the service. Another potential disadvantage is a question of whether the note will reflect the ideas of the physician versus becoming a transcript of the visit, including the important as well as extraneous information that might be difficult to wade through when looking back at a note.
As for us, we are still typing our notes into the EHR, for now. We remain intrigued by the range of approaches that are beginning to appear, offering options for solutions that improve the quality of physicians’ lives with attention to maintaining and improving the physician-patient relationship.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
