A post on the The MedFriendly Blog emphasizes the importance of proofreading transcribed medical records:
The medical record is a crucial piece of information that when it is not proofread and is left with either incomplete or incorrect information, it diminishes the ability of other providers to fully understand the case. This is poor practice.
Dr. Joel DiamondThese observations by Dr. Dominic Carone reminded me of comments from Dr. Joel Diamond, who discussed the promise of voice recognition software during our recent Healthcare Trends and Forecasts in 2008 webinar. Dr. Diamond is chief medical officer, North America for dbMotion, Inc., a provider of medical informatics and an active partner at Diamond, Fera and Associates, a family medicine practice:
Anybody that is looking at EMRs will ask about voice recognition. A year ago or earlier, if you had asked me about voice recognition, I would have said that I was totally against it because voice recognition to date is really the same as transcription or writing. It amounts to free text in the medical record, and the problem with free text is that it???s worthless. There???s no way of getting that data out of the record when it???s free text; if it???s structured data, then we can do something with it ??? we could learn, do research, perform process improvement. One of the reasons I???ve come full circle on this is that free text allows physicians to work faster. Because of that, there is a higher adoption rate of EMRs. We???re in a race, and that is why we have to get as many doctors using EMRs as possible. If voice recognition allows us to do that, then that would be great.
Keep in mind, however, that as we look at voice recognition, we don???t want to sacrifice the future by trying to save some time today. If we can get physicians to use this technology in a meaningful way and get them to focus on the present illness or the assessment plan, then we could do well. Doctors ask me what to extract from these EMRs. There are several examples that I use. I know doctors that have an EMR, but tend to use free text or voice recognition to record their medicine lists or their problem lists.
A few years ago when the medication Vioxx ?? was recalled, it was the first time in my professional life that I just went to the computer and typed in the word ???Vioxx??? and got a printout with the name of every single patient for whom I had prescribed the drug. In fact, I saw several patients for whom I had never written a single prescription for Vioxx but had just handed out samples to those patients. This was an incredibly useful tool for notifying those patients and informing them of what had happened. Without an EMR, I probably would have waited until they came to see me because there would be no way of auditing those charts. Similarly, had I free-texted those charts, I probably wouldn???t have been able to get at it as well.