Health Information Management

News: Study says dictated documentation less effective

CDI Strategies, June 7, 2012

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Patients of physicians using dictated electronic health records appear to be receiving lower quality care than those of physicians who use structured or even free-text documentation. At least that’s the findings of a recent study by Jeffrey A. Linder, PhD, division of general medicine and primary care at Brigham and Women’s Hospital, Boston. The study was published in Journal of the American Medical Informatics Association.

Linder and his colleagues suspected that physicians who more intensively interact with electronic health records through documentation may also be found to be delivering higher quality care to their patients. So, Linder conducted a retrospective records review of 7,000 coronary artery disease and diabetes patients over a nine-month period.  
They evaluated the quality of care of physicians who used three predominating EHR documentation styles: dictation, structured documentation, and free text.
“Quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles,” according to the abstract of the report.
“None of the three methods of documentation, by themselves, would fulfill the quality measures,” the authors wrote. “All three result in text within clinic notes.”

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