The positive impact of dynamic documentation

Ori-LotanDuring Cerner Corporation’s 2015 Physician Community Meeting in Kansas City, Ori Lotan, MD, Chief Medical Information Officer, reported positive results from early users of Crossings’ clinical decision support software.

 

Q: There has been a 50 to 90 percent reduction in transcriptions by physicians using dynamic documentation with voice recognition. How does this benefit them?

 

A: Hundreds of dynamic documentation notes are being generated daily at each hospital and the feedback from physicians – including surgeons and sub-specialists – has been very positive. Completing documentation with this tool reduces the physicians’ need to remember to review, correct and sign dictated documents. It also eliminates penalties, such as suspension of hospital privileges, for deficiencies if they fall behind in dictations. Having physician notes available in real time improves communication and dissemination of information among all clinicians.

 

Q: How does dynamic documentation improve the patient experience?

 

A: We built a lot of clinical decision support into the solution. This gave us the opportunity to improve many quality and patient safety measures by presenting them at the right time in the physician’s workflow. For example, when a physician adds a diagnosis that has associated core measures such as myocardial infarction, an advisor pops up that shows whether the specific core measures for that condition have been met. This appears as a check mark and green indicator if they have been, and an alert icon and red indicator if they have not. All deficiencies can immediately be addressed from this advisor by placing an order or documenting a contra-indication, bringing more efficiency and safety to the patient experience.

 

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Volume 1, Issue 2 – Summer 2015