Dictation is Public Enemy #1

March 15, 2010 at 5:33 am Leave a comment

Pete O’Toole

Healthcare is the biggest political issue in the US right now.  It’s a huge financial problem for everyone – individuals, businesses, the government and healthcare providers themselves.  It’s become so overwhelming that it has gridlocked congress.  The word “healthcare” just deflates everyone in the room each time it is uttered.  Despite all the frustration and everyone’s acceptance that “healthcare is broken,” most of us can’t name concrete problems in healthcare.  There is a vague sense that sometimes too many tests are ordered, but when it’s you who may need the tests, it’s not a problem.  Personally, I think that modern medicine is amazing, and nowhere in the world is it taught or practiced better than in the US.

I prefer to look for solutions to this crisis in places that do not take away from patient care.  For me, the first place to look is not in cutting screening for cancers – even if “only” 1 in 1000 people in a certain age range may actually test positive.  I think 1 person in 1000 is actually quite a lot to dismiss.  I realize there are excesses in the administration of healthcare — doctors who might be gaming the system, patients who might be hypochondriacs and lawyers who force doctors to practice overly defensively — and that it needs to be addressed.

The world's most powerful computer at Columbia University's Watson Lab, 1954.

There are many other places we can look to save money in healthcare.  One problem that will probably only get worse is medical transcription.  Decades ago, it made more sense for doctors to speak into a microphone and let a professional typist translate that dictation into a typed sheet of paper, than it did to try to make every doctor a professional typist.  When the first computerized medical records came out in the late 1960s, this practice naturally moved right over to support entry into these systems.  In fact, these systems were little more than glorified word processors, and many of them unfortunately have not progressed much beyond that point.  Early computer applications, although exciting, were hard to use.  Human-computer interaction as a field was barely born and would not influence the industry for a long time.  In the 1960s, this workflow made perfect sense.  Let doctors treat patients and let typists type.

Today doctors use computers in their personal lives.  They use iPhones, play Wii with their kids, keep up with friends on Facebook.  Many of them, let’s say roughly age 40 and younger, grew up with computers in their homes.  The rest have adapted like the rest of society.  The computer is no longer something beneath them.  In fact, many recognize its potential to enhance their abilities as physicians.

Why, then, aren’t software applications used directly by physicians more often?  Things are starting to change, but dictation still reigns supreme.  In 2004, the US spent $2.3 billion on outsourced medical transcription, and that number was expected to reach $4.2 billion in 2008.  (http://www.allbusiness.com/health-care/medical-records/4981139-1.html)  Despite the fact that so many physicians recognize the benefits of “computerization,” or “electronic records,” dictation is still a huge problem.

One problem is time.  Dictated reports can take anywhere from 24 hours to several days to be transcribed.  This is a problem for patient care because during this time there is a gap in the record on that patient.  It also delays the process of billing for services.

Another problem is the product of dictation — narrative text.  While there is nothing as rich as natural language, there is also nothing as inconsistent.  Free-form dictation means that doctors often forget to mention important items that we want to measure later, or they mention them in an inconsistent way that makes them hard to track.  A completely blank sheet of paper — or in this case the blank void of a dictaphone — is all flexibility without any consistency.  Every report done this way starts from scratch.

There are other problems with the dictation model.  Doctors have to review reports days or weeks later when the event is no longer fresh in their minds.  They have to correct the mistakes made in transcription by people who don’t know medicine.  The medical records department hounds them for signatures during time that could be better used helping patients.

At mTuitive, we’ve made dictation the enemy while building OpNote.  OpNote is a software application that lets surgeons directly complete operative reports.  They are available immediately for the patient’s record and for billing purposes.  The product of using OpNote is not freeform dictation, but a set of data elements that are extremely useful for research, tracking quality indicators and billing.  While doing this, we also give the surgeon the flexibility to change any answer or add anything unusual, and to build up a library of default reports that reflect his or her personal style.  In short, we figured out a way to let them use software directly without limiting their flexibility.  We’ve also managed to save them time compared to dictation.  And the checklist-style user interface is a helpful reminder to document aspects of the surgery that protect the surgeon later against frivolous lawsuits.

We’re targeting the dictation of operative reports, specifically, and our goal is to eliminate it completely.  We recognize that this won’t happen overnight.  We aren’t out to target the jobs of in-house transcriptions employed at hospitals or offices, because they will be needed for a long time to come.  But if we can even put a dent in the estimated $4 billion dollars spent on outsourced transcription, much of it on workers outside North America, we can save the healthcare industry an enormous cost.  This cost is being spent on a process that adds no value.  The product of dictation and transcription is still just a document that then must undergo another onerous process, albeit one that does add value for epidemiological and financial purposes — abstraction.  OpNote makes abstraction much easier as well, allowing the people who comb through operative reports looking for billing codes and quality indicators to do so with ease.  These people can now focus more on what to do with the data and how to use it to improve care than on just finding it.

At mTuitive, we don’t believe that doctors are lazy or that they don’t want to use computers in their jobs.  We think that most healthcare software is poorly designed and hard to use.  We think that there are tremendous industry pressures to keep a lot of things the way they are.  These things include bloated hospital information systems that are difficult to use, poor in functionality and insanely overpriced.  They also include outsourced transcription services that pay workers at home and abroad poorly and reap enormous profits.  In our experience, doctors are extremely intelligent people who want to use any tools that either help them provide better care or free them up to focus more of their time on care.

We are reaching out to many of these types of physicians in the surgical field, and their response in using the product has confirmed all of our suspicions.  The man behind the curtain of complex computer systems and the dictation workaround has been pulled back.  The secret is that there is no secret.  There is no reason highly intelligent men and women who use computers in every other aspect of their lives cannot use them as they do the most sophisticated work on the planet — fixing the ultimate machine, the human body.

Dictation — you’ve been warned.


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