Along with a fistful of cutting-edge technologies, an interesting trend has begun to emerge that may help predict a direction forward for the way users interface with electronic health records.
Hint: It’s not in the EHR. Instead, emerging technologies such as ambient listening, voice assistants and natural language processing will provide a subtle buffer between EHR data and users. Clinicians will be able to access and contribute to data within electronic health records software or cloud services, in fact, without having to touch the EHR itself.
Let’s take a look at how this could play out.
EHRs today
As they have evolved, EHRs have also become more complicated and “busy.” They require significant investment in training, both prior to adoption and ongoing as new features are released.
Telling a primary care group back in 2000 that 6-8 hours of classroom training was required for every physician would have been the ultimate non-starter. Today, this is the norm and accepted as reasonable and it also holds true for the analysts who configure and support these systems of record.
Documentation requirements continue to increase, too. The push to document in a codified way has become more important in order to inform not only electronic decision support but also to support population health management initiatives and advanced data analytics. Plus, medical knowledge is eclipsing providers’ capabilities to internalize it and incorporate it into their practice.
So what does this point to?
Voice recognition, NLP and remote scribes
Providers have already begun to adopt technologies such as voice recognition and natural language processing that allow them to distance themselves from the complexities of the EHR.
Since a clinician is technically in the record while dictating via voice recognition, he or she is interacting with the system with a software buffer that the typist does not have.
A more pronounced example is the scribe. Far from a new idea, the scribe allows the provider to see the patient and remain fully focused on the task at hand while someone else does the documentation on their behalf. While this comes with a certain level of awkwardness for the patient, it has been widely adopted in some clinical settings.
Natural language processing has been discussed in concept and used in pockets for many years. While loaded with potential and extremely appealing, it has yet to take off as a full-fledged documentation solution.
More innovative alternatives are also being explored. Remote scribes allow the transcriptionist to listen to the visit in real time and document as the provider speaks their way through the examination. his may be implemented as an audio-only solution or with audio and video through the use of a tablet or some other video-enabled device in the exam room. Ambient devices are also being investigated as alternatives — pairing voice recognition with a mostly hands-free documentation experience minus the scribe. Google Glass is another interesting alternative. In this concept, the provider is not only dictating as they examine the patient but also visualizing elements of the record as they go without having to refer to a computer or tablet.
Tech challenges and costs
These novel technologies are not without challenges. For the remote scribe model to be successful – especially in the case of audio only – providers need to run through their visits in a common way for the process to be accurate and efficient. The scribe also must document the right information in the right place in the record. If they are merely typing a free text note – the value of the data is lost. Decision support is one of the most compelling reasons to use an EHR. How can the provider receive this guidance if they are not interacting directly with the system? A hybrid solution could solve for this – with the provider manually performing order entry and prescribing tasks. Alternatively, technology developers may come up with an innovative solution to address the requirement in the future.
Patient perception is also a concern. As with the traditional human scribe, patients may react negatively to the notion of a virtual third party participating in their visit. How can the patient be sure that only the identified third party is listening/watching? How can they be assured that the visit is not being recorded or shared? What type of consent is required and what details need to be shared with the patient in order for them to be aware of the process? What if the patient declines to participate in this type of visit?
Security, of course, will be paramount both for the patient and the hospital. We all hear of major security breaches on a weekly basis. Executives and (increasingly) patients will need guarantees that these solutions are secure and insulated from the risks that come with the possibility of a data breach.
Traditionally the solutions that allow providers to document patient care without interacting with the record have been utilized mainly in the ambulatory, urgent care, and emergency department settings. Is there an option that would work for inpatient providers? Is there an option that would be suitable for nursing documentation? It may very well be that the answer is “no” and that these caregivers will continue to document directly in the record (either manually or with traditional voice recognition) for the foreseeable future.
Back to the future
There is, of course, a financial component to all this as well. Scribes and the more advanced technologies described are not inexpensive. It will be up to technology developers and service providers to clearly articulate the return on investment. It is noteworthy that some of that ROI will be difficult to quantify in terms of dollars or efficiency as it relates to provider happiness.
Even with all of these questions, it is clear that the trend of providers moving further away from direct interaction with the EHR is real and likely to continue.
Ideally, EHR developers and regulatory agencies will see this as a challenge to simplify their products and documentation requirements. It’s possible that this is the push the industry needs to rethink usability and truly develop intuitive systems that are easy to learn and easy to use. This will require not only creativity and skill, but also a willingness to rethink many of the constructs the industry has operated under for the last decade-plus.
It is more likely that the burgeoning trend will continue to progress and we will find ourselves in a “Back to Future” scenario where providers use the medical record to access information, but harness various forms of new age dictation to keep it updated.
Michael Sperling is Executive Director of Information Systems at South Shore Health System in Weymouth, Massachusetts.
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