South Florida Hospital News
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September 2007 - Volume 4 - Issue 3

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A New Trend: The Focus on Information Capture in Hospitals

Information technology can help hospitals become more competitive and gain benefits that range from linkage to medical practices and reducing medical errors to improving quality of care. In addition, physicians and hospital staff can benefit from electronic care and management processes. However, most of these benefits depend on one issue, namely how easy and convenient new computer systems are for physicians and staff. Implement a new information technology (IT) system that is not liked by physicians and it will be declared a failure. It is the selection of the right devices, processes, systems and policies for physicians, nurses, and other users to document, access information, and interact with computers that is the critical element for any CIO. Whether one uses tablets or light-weight smart phones, new ultra-mobile personal computers (UMPCs) or a computer pen will determine whether an EMR installation succeeds or fails. When physicians, nurses and others can document, access, and transmit information at the point of care (bed-side, exam room, at the operating table, etc.), there is better quality of documentation than when these activities are done at the computer desk. It is one of the best kept secrets that these decisions affect the quality of care of care tremendously.

This is what information capture is all about. Every hospital is facing four major decisions. The first is whether a hospital should continue with traditional medical transcription or save millions of dollars with speech recognition or other new technologies. Everyone is familiar with the shortcoming and exorbitant costs of medical transcription and the frustrations of physicians and hospital staff with quality, turn-around time, and accessibility. As an alternative, back-end speech recognition can help, but only to a limited degree. Costs can be reduced much more with front-end speech recognition, where the user manages the documentation process (including corrections and signature) herself at the time of dictation. Speech recognition has had a history of false promises. In the past, people who tried it soon gave it up because it was too complicated, took too much time, and had low accuracy. Recently, however, this technology has made great progress. At the national TEPR conference in May this year, a young physician told the audience of 2,000 that speech recognition "is fun", that it improves quality of care, and that he has more time for his patients and himself because of it. However, what made people really listen was his statement that he "doubled his income" with the adoption of speech recognition and an EMR.

Speech recognition is still not for everyone, nor is it likely that will be, but those hospitals which are using it for some document types by some clinicians are reporting great savings. The same applies to digital paper, where forms are completed with computer pens which simultaneously allow writing on a paper form and recording it on computer.

To make information capture even more complicated, users prefer specific PDAs, smart phone, or mobile computers. Ask around and you will find that each physician or nurse has his own preferences. Therefore, the second decision a hospital has to face in its information capture strategy is a design that integrates all these devices.

Third, there is the most neglected aspect of information capture, and that is the legality of documentation. While hospitals spend resources on risk management and compliance, these activities rarely address the risks of inadequate documentation. Where is the compliance with the principles of documentation that are the base of good care and the defense against legal and reimbursement problems? Hospitals must create appropriate policies for information capture that ensure economic, well integrated digital computing processes that are legal and efficient. This includes such decisions as how to deal with duplicate paper backup that is out of sync with the computer system, what is legal digital documentation, and when can you go paperless (read, go electronic without having paper backups) and save millions?

C. Peter Waegemann is CEO of Medical Records Institute. Medical Records Institute has been a leader in this field for years. Its National Conference on Health Information Capture will be held November 4-5, 2007 in Fort Lauderdale FL. It is the only conference that focuses on all major issues of information capture. For more information, visit the web at www.medrecinst.com/infocap07.asp or call (617) 964 3923 ext. 203.
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