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Using Speech Understanding™ to Power Clinical Documentation, Technology Adoption

While Meaningful Use-certified Electronic Health Records have become the de-facto standard and a must-have technology for most hospitals and increasingly clinics and physician practices, physician adoption of EHRs has been lagging – for well-understood reasons. Physicians have a strong need and desire to maximize their time with patients. Yet, technology is competing more and more for their time, and creating structured clinical documentation using EHR templates may actually negatively impact physician productivity in a point-and-click environment.

Despite the availability of significant amounts of federal stimulus dollars to Meaningful Use-compliant institutions, most physicians perceive this to be less critical to widespread EHR adoption than access to tools that simplify, speed-up and improve the quality of clinical documentation within their EHR. An essential part of improving the quality of clinical notes is the capture of a more complete patient story via physician narrative to complement the less expressive point-and-click templates. Without such narrative, and due to widespread copy-and-paste-forward behavior, clinical notes lack documentation of the physician thought process that is so critical in coordinating care among multiple care providers. In the words of one physician: “I am looking at eight pages of detailed, structured EHR documentation and still have no clue what’s going on with this patient.”

This explains why physician narrative has always been the most popular mode of physician documentation. On average, 60 percent of a patient’s medical history still resides in unstructured clinical documentation. And with the recent availability of powerful speech and natural language understanding tools that liberate the clinical content hidden inside those narratives, that number is likely to go up rather than down. In the past, narrative clinical documentation was simply neither accessible nor actionable from a computational perspective – but that has changed rapidly in the last few years.

Today, we can capture validated clinical data directly from physician narrative in real-time, and use it to drive Meaningful Use and Quality Measures reporting, abstracting and billing needs – all of that without making physicians point-and-click through pages and pages of structured templates. This not only delights physicians by allowing them to spend more time with their patients again, it also results in more meaningful clinical documentation that physicians find more useful as it tells the patient’s story and contains all the relevant clinical facts and considerations, rather than putting too much emphasis on just the reimbursement requirements.

The recent advances in Speech and Natural Language Understanding technology are giving physicians the best of both worlds – efficient narrative documentation and compliance with regulatory and financial requirements – something that traditional speech recognition technology is not capable of delivering. These new technologies implement a closed loop documentation workflow where physicians receive guidance about documentation requirements and compliance based on an understanding of the content of their narrative documentation. This allows the physicians to get to the right level and specificity of clinical documentation (key use case: documenting appropriately for ICD-10) in a once-and-done workflow, as opposed to receiving queries from coders or CDI specialists at a later time when it is a huge disruption.

QUESTION: With the continuous increase in regulatory requirements relative to clinical documentation (Meaningful Use, quality measures, ICD-10, value-based purchasing), healthcare organizations have to ask themselves: how do we keep physician productivity and quality of clinical documentation high while driving adoption of our EHR? If you have a minute, let me know your thoughts on this!

You can hear more on this topic at ACE 2012, where I will present on “Driving Adoption of Clinical Noting Through Speech Understanding.” August 16 at 11:45am in W196A.

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