The dilemma of medical documentation: GP and practice manager’s response to EMR

With growing numbers of patients, and the increasing need for all patient records to be stored and accessed electronically, medical documentation is becoming a burden for many general practitioners and practice managers.

Accurate, in-depth patient records can, of course, enhance the level of care given to a patient. But with increased amounts of time being spent on medical documentation, many NHS staff are finding it difficult to actually find sufficient time to spend with those patients. This presents a dilemma.

Recent research has revealed that:

• 50% of doctors’ time is spent on clinical documentation
• The amount of time wasted is equivalent to three outpatient clinics per doctor per week.

Finding a solution

While some might view the introduction of electronic medical records (EMR) as an added pressure, there is also a technological solution within easy reach which can save considerable amounts of time.

With 11,000 patients treated a year and these numbers steadily rising by 5% annually, Dukinfield Medical Practice in Tameside was one such practice which was feeling the pressure of medical transcription.

With the retirement of one of the practice’s secretaries, Practice Manager Julie Pregnall found that the time was right to investigate digital solutions. The discussions that took place eventually led the practice to adopt the speech-to-text solutions provided by Dragon Medical Practice Edition.

The road to Dragon Medical

• Prior to trying Dragon Medical, the practice’s six GPs had been recording patient notes verbally using digital voice recorders. These electronic files were then transcribed by the secretaries. This system resulted not only in a duplication of effort, but also in backlogs when secretaries were away or were engaged in other vital work.
• After having Dragon Medical recommended to her by another practice, Dukinfield’s Practice Manager engaged the services of one of Nuance’s reseller partners to begin the process of switching to the software. Dragon Medical was set up for each of the GPs, and one-to-one training was provided to ensure that the correct medical vocabulary was set up and that the team knew how to use the software.
• Voice-recognition user profiles were set up on a shared drive, so that when doctors needed to work from a different area they could easily dictate medical notes wherever they were in the building.
• While the previous dictation and manual transcription method took considerable amounts of time and led to backlogs, Dragon Medical’s speech recognition solution allows GPs at the practice to transcribe directly to electronic patient records (EPR) at speeds of up to 160 words per minute. With an accuracy rate of up to 99%, doctors felt comfortable relying on the software, while secretarial staff were free to concentrate on other, more patient-focused tasks.
• Feedback from GPs at Dukinfield Medical Practice stated that patient letters were able to be more detailed than ever before, and that by capturing a more complete view of the patient story they were able to provide better care.

Find out what Dragon Medical Practice Edition can do for your practice.