Case study: Article from the The British Society for Human Genetics

Finding Options for the Typing of Clinic Letters

Each year when our Trust scrutinises our budget, apart from salaries it is the quantity of paper that we go through that causes the most comment.  “What do we do with it? where does it go?”, are amongst the questions.  I emphasise that this is what we do; we write to the many people involved in the management of the complex, multi-system conditions that we see.  In mitigation, I point out that we have no drugs budget and communication in genetic counselling is our fundamental raison d’etre.  With this goes typing and lots of it, bundles of notes and tapes that overflow our office shelves.  We have had six or at times, eight week backlogs for letters going out when staff illness, especially the risk of repetitive strain injury (RSI) or holidays impact on the service. 

So there we were in middle of 2007, up the creek without either a paddle or a typewriter in sight.  We needed a fix and quickly and agency staff were proving expensive, of variable quality and unimpressive reliability.  We had heard that some clinical genetics centres around the country were using overseas typing agencies to handle their work and on our behalf the Trust explored this. We made the stipulation however, that we wanted it to be UK based to maximise the quality of the typing and their assurances for confidentiality. We were directed towards the Dict8 scheme (www.dict8.com) which quickly became very popular with our service.  It has been easy to introduce, the quality of the returned material has been as good as anything previously typed in-house and the speed of return has been breathtaking, sometimes as little as two hours from dictation to delivery back via their website.  The returned text still needs to be formatted into appropriate letters and printed out for signing and there is the cost of this Rolls-Royce service.  

Initially the four Consultant Clinical Geneticists were equipped with hand-held digital recorders, (Philips 9360), but we quickly added four more for the SpRs and a further three to share amongst our genetic counsellors and trainees.  The Phillips recorder is battery operated (a set of AAA batteries may last about 2-3 weeks) and does not need to be plugged into a computer to be used.  It is very similar to a conventional hand-held cassette tape recorder and the dictation is stored on an easily accessible memory disc (about 1 inch square) that can hold more than 50 sets of clinician and patient letters.  With digital dictation you can edit your dictation, insert additional text, mark and delete a passage even before it is sent for typing.  Once dictated onto the memory disc, the voice files of these letters can be accessed, copied or deleted by connecting the digital dictaphone into the USB port of any computer in the same way that you would read a USB memory stick or a camera photocard.  No special software is needed for this.

Dict8 have a dedicated website with password protected log-in for each member of staff.  This allows us to upload our dictation into the dict8 secure workspace area.  I finished one clinic at 5.30 pm and uploaded my dictation files at that time.  It is very easy to see which dictation files have been uploaded, and then those dictated files that are in the process of typing.  Returned files are tagged with the Genetics file number for that family and can be opened again via the password secured website into a Word document and saved in whatever format you choose.  Clinicians can check their letters on screen at this point and make any minor changes that are needed.  A secretary or clerical member needs to top and tail the letter into the desired style and format for your clinic service ready for signing and posting.  Our liking for the system is its sheer simplicity, that you take to it so quickly and it is so user-friendly. The quality of the returned typing is excellent including genetics terminology.  We are assured that all the typing is done in the UK by carefully vetted secretaries with several years experience of medical typing.  An advantage for us is that letters can be composed with patient names and addresses, reducing the risk of merging anonymous text with potentially the wrong patient identifiers.  It seems to work in all aspects providing one is confident of the integrity and confidentiality of the dict8 typists.  We understand the typing staff work from home picking up the work via the secured website.  They are self-employed and paid on a piece rate for the typing they return to the dict8 website.  In fact one of our previous secretaries is now working for them!.  The dict8 website and any work to be uploaded or retrieved can be accessed from any computer connected to the internet.  Literally letters can be dictated from clinic in Crewe, uploaded in Upton and the letters will be ready in Liverpool, often within 12 hours.  The speed up in our letter process has been truly phenomenal, without the need for any complex training or compromise in the quality of our letters.  

 

Written by: Dr Ian Ellis   FRCP BSc Consultant Clinical Geneticist. Text from the full article has been used with the kind permission of the author and the BSHG.

This is an abridged version of the article that original appeared in the February 2008 issue of the British Society for Human Genetics Newsletter. You can download the issue (38) here – the article is on page 44.

 

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