With the national push toward electronic medical records, there have been active efforts to upgrade clinical data and systems software. At some institutions, an effect of this transition is the migration from the traditional voice dictation systems or paper clinic notes to a typed electronic record.
A recent study at the University of Toronto Faculty of Medicine sought to evaluate the overall quality of electronic discharge summaries (EDS) compared to their traditional dictated counterparts. The measure for quality was based on a 100-point visual analogue scale rating the satisfaction of primary care physicians (PCPs) who receive the discharge summaries. Other endpoints studied included the satisfaction of house officers using either system (again, using a 100-point visual analogue scale), adverse outcomes after discharge (combined emergency department visits, readmissions, and death), and patient understanding of the discharge details.
Four general medicine teams at the St. Michael’s Hospital were recruited during one housestaff rotation between May to June 2008. Two teams were randomized to the EDS arm and the remaining 2 teams were assigned to dictate their discharge summaries. All discharge summaries were drafted by the housestaff. During the study period, there were 209 patient discharges with 105 EDS and 104 conventional dictations generated. There were 188 surveys sent with 119 returned (63% response rate).
There was no overall difference in PCP satisfaction and in the assessment for quality, completeness, organization, and timeliness. There was no difference in the adverse outcomes (22 for EDS, 21 for dictation; p = 0.89) or patient understanding of discharge details. There was also no difference in housestaff satisfaction using either system, but they found the EDS significantly easier to use (86.5 for EDS, 49.2 for dictation; p = 0.03). The time burden was longer with typing than with dictations, but not statistically significant (mean 36.8 for EDS, 55.2 for dictation; p = 0.23; 0 = time consuming and 100 = not time consuming). The authors concluded that “An EDS program can be used by housestaff to more easily create hospital discharge summaries, and there was no difference in PCP satisfaction“.
The use of an EDS has its many advantages. Typing allows periodic updates of discharge summaries, which can be particularly helpful with patients whose hospital stays extend for months and cross over multiple inpatient teams. Typing permits immediate proofreading and error-correction (typographical, grammatical, organization), while allowing the physician to arrange disorganized thoughts and data more coherently. There are also the cost savings of not having to hire medical transcriptionists. On the other hand, some perceived drawbacks of an EDS may include “information overload”, “loss of focus on useful data”, and inconsistent or outdated information resulting from less rigorous copy-and-paste habits.
The authors added that the “(h)ousestaff appeared to prefer the EDS method overall.” While this may be true for the study participants, this is an assessment that cannot be generalized across the spectrum of physicians. For one, the current Facebook generation of trainees are uniformly adept with the keyboard and comfortable with emerging computer technologies. Their older counterparts, however, may be less skilled with typing and therefore not find an EDS to be as easy or intuitive to use.
More importantly, the housestaff who generated the discharge summaries were likely interns responsible for the patients admitted to their team. They are invariably less experienced with oral dictations than with typing. This already creates an unfair advantage for the EDS arm than the dictation arm. Similar to typing, voice dictations have a steep learning curve, but can be learned. I posit that the similarity in reported time burdens for both methods reflects the inexperience of the housestaff with voice dictations.
An experienced oral dictation is almost always faster than data entry by an experienced typist. Advanced typists can reach above 120 WPM (words per minute). Contrast this with political debaters who can speak from 350 to 500 WPM. While I have not reached the speed of those political debaters in oral dictations, I have heard some physicians who can generate dictations at similar speeds.
I regularly use both electronic and voice dictation systems for writing clinical notes at different sites. I feel comfortable typing blindly with the keyboard, and was initially a strong proponent for keyboard-based note entry. However, after gaining more experience with voice dictations, my preference has shifted. In a work environment where we are continually given more work with less time, I would favor the method that would permit me to also accomplish more work in less time … and according to the study, without sacrificing quality. Now that’s a good deal!
- Source
- Maslove DM, Leiter RE, Griesman J, Arnott C, Mourad O, Chow CM, & Bell CM (2009). Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled Trial. Journal of general internal medicine PMID: 19609623
