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Optimizing and Using the EHR in Rochester, MN: A Case Study

STEPS in Practice

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Jose Ortiz, Jr., MD is an orthopaedic surgeon at Mayo Clinic Health System in Eau Claire, Wisconsin, who uses real-time dictation to document patient visits. Dr. Ortiz was initially introduced to dictation in residency when one of the attending physicians he worked with used this method of documentation. He would obtain a history, complete a physical exam, perform patient education, and answer all questions; then, dictate the visit in the exam room with the patient present. Dr. Ortiz took this experience with him and adopted it in his own practice.

When Dr. Ortiz first started practicing, he would carry portable phones with him from room to room in order to dictate. Later, he moved on to a dictaphone, and as technology advanced, he moved to a mobile device. Currently, he uses voice recognition software to dictate directly into the desktop computer in the exam room. He uses "real-time" dictation; this technique has greatly improved his efficiency by allowing him to see the patient and dictate at the same time. Dr. Ortiz says, “Real-time dictation has revolutionized my time. I frequently leave about 15 to 30 minutes after my last patient and do not stay after to dictate, nor do I dictate from home”. In addition, he has not made any appointment time adjustments.

By seeing the patient and dictating simultaneously, he is able to collect information and document it in real-time. This is an example of a typical patient visit workflow:

  1. Dr. Ortiz knocks on the door, enters the exam room, and introduces himself to the patient.

  2. The reason for the visit is discussed with the patient.

  3. Dr. Ortiz introduces and explains the dictation process to the patient and then proceeds to document the reason for the visit while maintaining contact with the patient to ensure accuracy.

  4. He documents any pertinent past medical history, family history, social history, current medications, and allergies.

  5. A thorough physical examination is performed, and upon the conclusion, he dictates the exam into the note. Sometimes, he will even let the application run and while examining the patient, dictate aloud so that he is examining and documenting information into the note simultaneously.

  6. He continues, dictating the impression, and pauses to discuss the impression with the patient.

  7. Dr. Ortiz performs patient education, answers any questions, and then develops and discusses the treatment plan with the patient.

  8. Finally, he will slowly dictate recommendations into the note in a manner by which he is reemphasizing to the patient key parts of the treatment plan.

Dr. Ortiz has found this approach to be very beneficial. When he is done seeing the patient, he is also done with the dictation. By dictating in front of the patient, it ensures that the note is accurate and emphasizes the care plan to the patient.

Dr. Ortiz has had such success with real-time dictation that he has discussed the approach with some of his colleagues. They have expressed concern about dictating in front of the patient; however, patients have access to their electronic health record, so there is nothing that can be documented that the patient won't be able to see. In fact, Dr. Ortiz has found that using real-time dictation provides the opportunity to stop and clarify anything that might seem offensive to the patient at the time of the visit, eliminating any surprises if the patient reads the note later.

In his practice, many patients comment on how nice it is to hear what Dr. Ortiz has to say, live and in person. Ironically, it is the older patients who appreciate it the most. An important result of live dictation has been the patient's ability to correct him. He says, “Patients stop me to correct me with either a date or the side, right vs. left, or to clear up a detail I misspeak”. Patients often praise this way of dictating, and have expressed the wish that all of their physicians did it this way. Dr. Ortiz currently has the second highest satisfaction scores in the department, which he attributes to this method of dictation and its impact on the patient experience.

Dr. Ortiz has had many colleagues that say this method would not be possible in their clinics. However, he challenges them to give it a try. Those who have tried real-time dictation have found great success with it.

Many of his colleagues are intimidated at first and think they are too busy to do this, but later find it is a time saver. They soon realize that they are actually working in parallel. For example, instead of verbally reviewing the history with the patient to ensure it is correct, dictate it! Dr. Ortiz explains, “The patient listens, adds commentaries, or corrects you – but then you are done reviewing it, and it's in the record.”

Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
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