Dictation versus Template Systems in the Emergency Room

In the United States there has been a movement for Emergency Doctors to record the patient visit by using a charting system called the T System. This is one of many check off template systems that have gained huge popularity for the reasons of convenience and ease of use, resulting in replacement of dictation services in many emergency departments. I believe that these systems undermine the goal of charting. As I see it these are:

1. A record to enable future Doctors and care givers to understand what took place at the time of the patient’s arrival into the hospital.
2. To enable a legal document which can record the thought process of the Doctor at the time of patient consultation.
3. A document from which healthcare finances can be organised.

Arguments are made in favour of tick box templates and that the record is
immediately available for future health carers. In contrast to dictations can take some time to come back after transcription. But the real reason for template use within Emergency Rooms in the US and perhaps in the UK, is that it is much cheaper than dictation and is also easier, as the skill of dictation is not learnt by Emergency Room Physicians. My concern, however, is that tick box templates may result in an inaccurate record of what happened. I worry that medical staff will get used to ticking all the boxes without actually taking time to accurately process the examination just completed. Some of the template schemes I have seen do not have enough space next to the boxes in which to put an elaboration on the physical exam. It may also be that the incorrect box is inadvertently ticked. However, most importantly, such a brief record of a patient visit leaves almost no memory of the patient within the Doctor’s mind and this can have medical legal consequences if the chart needs to be reviewed sometime in the future as the Doctor will have a very poor record of his thought process at the time.The ideal system would be to have some combination of a charting systems. Here the doctor is prompted so that he does not forget certain exams and the chart also leaves adequate space for elaboration which could be filled in via dictation in predetermined zoned areas. Dictation works by also enabling thought processes to be conveyed in a legible manner. It is frustrating to try and read the illegible scribbles written on a chart by time pushed doctors with poor penmanship.

In conclusion, I believe that dictation of charts enables continuity of care, medical legal defence and appropriate costings to happen in a smoother and more efficient manner which in turn creates cost savings that eclipse the up front higher costs ofthis process.

By Dr Sebastian Zeki – January 2008

The problems associated with delayed typing- a doctor’s experience

Doctors do not work in isolation. They rely and are relied upon by patients, as well as a whole network of other health professionals. The web that ties all of us together relies on efficient and exact communication streams of which there are many examples. None however is more tried and tested than the written letter.

Long before the NHS, healthcare systems in the UK have relied on letters to detail patient consultations to others, including the patient themselves. The importance of a documented account of the meeting between patient and doctor becomes more evident the more complex healthcare systems become. It acts as a legal document, a note of reassurance, an exact layout of a treatment plan, and as such it becomes a documented trace of a patient’s journey through a complicated system.

The letter has not been replaced by newer technologies, such as phone, and email and in fact the NHS produces an estimated 12 billion lines of written text from consultations every year. This number continues to rise. The success of the letter may be partly a function of the disparate development between letter delivery systems and email or other telecommunication systems (the former having been around for hundreds of years) as well as it being more nebulously trusted.

My daily life is consists of the reading and writing of letters, and it is on these that I largely depend to tell me about a patient. I may see a patient in clinic and make decisions that will need to be acted upon urgently so I need to know that the letter that is dictated in clinic will be delivered. This is the problem with letters- there are too many stages between its creation and its delivery. I dictate, the tape is sent to the secretaries pile, and a week later I get to check the letter for errors. If there are none (if), it gets sent.

The problem is more clearly illustrated with a patient I met whilst doing an oncology job. The patient had recently been diagnosed with lung cancer, I had to dictate a letter to his GP so that he could have the adequate amount of oxygen in his house, as well as to the palliative care team who would look after his symptomatic needs at home. The letter was dictated. A week later I got a call from the GP to tell me that the patient had died, unexpectedly for the GP, at home. He had not had the palliative care support and apart from his family, had not had anyone to care for him during his final days. He had also not been given the oxygen he required at home. I went upstairs to the secretary’s office to find my badly spelt letter awaiting correction.

The advantage of digitising the process is that it is faster. The letter gets dictated and uploaded. Twenty minutes letter it is typed (often with minimal if any errors) and ready for signing. It can be emailed, or even sent for mailing at the click of a button. The additional advantage is that the letter can be retrieved easily. There is no need to dig through four volumes of notes as the letter can be found with a simple search. The whole communication process is sped up to the extent that information can be shared between practitioners before the patient has even returned home from a consultation.

I am a great advocate for the paper being in the hand, but before digitisation of the process, we were failing to deliver with the haste that healthcare needs to provide anything worthwhile. The faster the communication, the better for the patient.

 

By Dr S Zeki