Doctors’ EHR note-taking method affects quality of care

Physicians who dictate patient notes provide a lower quality of care than do doctors who use structured documents, a study says.

By — Posted June 12, 2012

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Physicians who have electronic health record systems but dictate patient notes give a lower quality of care than do doctors who use structured documentation, says a study published online May 19 in the Journal of the American Medical Informatics Association.

“Dictating may be easier for the doctor...[but he or she might] not be paying as close attention to information and alerts in the electronic health record that are important for patient health,” said lead study author Jeffrey A. Linder, MD, MPH, associate professor of medicine at Harvard Medical School in Boston.

Researchers evaluated 18,569 primary care visits by 7,000 patients with coronary artery disease or diabetes in eastern Massachusetts. The visits involved 234 doctors, and occurred between 2007 and 2008. Researchers also examined 188,554 patient visit notes written by the physicians for all of their patients.

They found that 62% of physicians mostly used free-text notes, 29% used structured documentation and 9% mainly dictated their notes. The structured format uses templates that divide the patient visit notes into separate sections, such as history of present illness.

Doctors who predominantly used dictation were older, had more patient visits and were attending physicians compared with those who used other note-taking methods (link).

Dictations were done via telephone and transcribed, and then uploaded to the EHR by a third-party transcription service. Free-text notes were created using a single window, similar to a word-processing program.

The main outcome measures were 15 coronary artery disease and diabetes measures that researchers assessed 30 days after the primary care visit. Quality measures were considered fulfilled if the information was present in specific EHR-coded fields.

Researchers found that quality of care was significantly worse on three outcome measures for doctors who dictated their notes compared with physicians who used the other two documentation styles. Those measures were antiplatelet medication, tobacco use documentation and diabetic eye exam.

For example, tobacco use status was documented in the EHR of 22% of patients who visited a doctor using dictation, data show. The measure was documented for 36% of patients who visited a doctor using free-text notes and for 38% of those who saw a doctor who used structured documentation.

Quality of care was significantly better on three measures for doctors who took structured notes compared with physicians who used the other two styles, the study said. Those measures were blood pressure documentation, body mass index documentation and diabetic foot exam.

Doctors who used free-text notes had better quality of care in providing influenza vaccinations. No measure was associated with higher quality of care for physicians who dictated their notes, the study said.

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