Required Structured Data Only Small Percentage of Typical Patient Note
Naples, FL, Oct. 7, 2014 /PRNewswire/ -- A new industry study released today and shared by MedScribe Information Systems (www.med-scribe.com) indicates that as little as 7% of data in a typical patient note is required to be structured in order to meet Meaningful Use. The percentage rose to 9% when lab data was present.
The industry study analyzed one hundred de-identified orthopedic and cardiovascular patient notes obtained from MTSamples.com. While a larger body of documents needs to be analyzed to confirm study findings, the key takeaway appears to be that as much as 91% to 93% of data typically captured within EHRs in a structured format (e.g. point-and-click templates and drop-down boxes) could instead be captured as unstructured data (e.g. dictation and transcription, or free-text entry) and still meet Meaningful Use requirements.
"Physicians are confused about what type of data needs to be in a structured format to qualify for Meaningful Use Attestation," said John Langley, Med-Scribe's founder and CEO since 1992, Physicians are entering more structured data than is required which adversely impacts physician productivity and reduces face-time with the patient."
Data sets required to be structured for Meaningful Use are:
- demographics (preferred language, sex, race/ethnicity, date of birth)
- vital signs (height, weight, blood pressure, BMI)
- smoking status
- problem list
- medication list
- medication allergies
- lab tests/values
- minimum of one Family History entry
According to Elisabeth Myers, Policy and Outreach Lead at the CMS, much of the data routinely documented as part of the patient encounter - such as the History of Present Illness, Assessment,and Plan, to name a few key document sections - can be incorporated into the patient record within the EHR as unstructured data without in any way preventing the physician and clinic from meeting Meaningful Use.
"EHR adoption continues to be a struggle for physician practices and clinics when it really doesn't have to be that way," said Langley. "By incorporating the faster and easier option of dictation and transcription into the overall EHR documentation process, more details of the patient encounter can be more easily captured which helps tell the whole patient story."
MedScribe's mobile dictation app allows the doctor to dictate from their own iPhone making dictation more convenient than ever . In addition, "virtually every EHR is capable of incorporating transcription into the patient note via what's called an interface," said Bill Langley, VP of Operations for MedScribe, 'setting up an interface can take anywhere from 30 minutes to six weeks, and requires the cooperation of the EHR vendor."
MedScribe Information Systems has been an industry leader of U.S.-based outsourced transcription services since 1992. MedScribe has extensive experience interfacing with different EHR's and looks forward to providing interface and service references upon request.