For many years, the best solution to solving all of these problems surrounding reporting was using dictation and transcription. Dictation and transcription can be a powerful and helpful tool, particularly for entering in your own notes that may not be needed for patient care or containing important health data that could be used by others. However, with innovations in technology and an improved understanding of medical workflows, time is running out for using dictation and transcription for operative reporting, radiology reports, or even pathological findings. Here are the top 3 reasons to ditch dictation and trash transcription:
1) It's Inconvenient
This may surprise people, as they think "what could be more convenient than picking up the phone to fill out your report?" It's an illusion of convenience. For most dictation programs, you have to be using the services in the facility - you can't call in from another site. Or else it's a long process to call in and authenticate. We know that a lot of surgeons, for example, move between doing procedures in hospitals, ASCs, and even their own offices. By tying them to just one option at one location, you're severely hampering the ability to report effectively. If they have to wait to record their findings, there's a chance they may forget important information or else confuse elements with different cases. Also, picking up the phone and quickly dictating may seem convenient - but it's important to remember that is just the first step of the reporting process. Because there's another reason that dictation should be discarded...
2) It's Incomplete
Dictation by itself is not medical reporting. Someone has to transcribe those words. And even if you use speech recognition software (or back end speech recognition software that types out a recording of your dictation), you still need to proofread what was written down. This goes back to dictation being the illusion of convenience, when in fact it's just delayed inconvenience. After dictation is complete, the next step is for that report to get written up and sent back to the physician for approval. The transcription of the report needs to be proofread in case any words are misspelled, the transcriptionist couldn't hear what was said correctly, or there's anything you (as a physician) wanted to include but forgot to when you dictated. Then, if there are any changes, you have to make them and resubmit to be re-entered and then come back to you for approval before that report goes into the record for the patient. That delays information getting to the other physicians as well as slows down reimbursement. Dictation seems easier to do, when in fact it has so many other steps attached to it - and each step represents time that physicians have to spend going over the report, or waiting for it. It's an ongoing concern as opposed to a solution that can be finished in one fell swoop. If physicians can build their reports in front of their eyes, it allows them to sign off on it and be done with it. It also takes care of the third reason to ditch dictation and transcription...
3) It's Inexact
There are multiple studies out there that show how synoptic operative reports and electronic operative reports are more complete than those created by free form dictation. This is because, while it is part of a routine and therefore easy to get into a rhythm, it's just as easy to leave information out. By speaking extemporaneously, and without seeing the report you are creating before your eyes, it's very easy to confuse elements (especially given the high case volumes
Working in the medical reporting field, we ask prospetive users "how long does it take for you to report on a case?" and they usually answer a matter of seconds. They mean how long it takes to dictate that report - not factoring in the time or costs it takes to transcribe the report, proof the transcription, edit the transcription, approve the transcription, upload the transcription. It also doesn't take into account the researchers and other physicians who have to search these archived reports hoping to find relevant information necessary for vital medical research or improved patient treatment, not sure where the information they seek will be located or how it will be phrased. Picking up the phone seems like a real convenience, until you see all of the complications waiting on the other end of it.