Ben Lewis

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True dictation of clinical staff notes straight into the electronic medical record (eMR)

A few weeks ago I shared a little light bulb moment on LinkedIn and it quickly became one of my most viewed items. 

Click on the image to be taken directly to the LinkedIn item.

Background

I unfortunately had to spend 15 hours in Royal North Shore emergency department and whilst sitting there got to quietly observe how the staff went about their various tasks. Not to pry or snoop, but out of curiosity, as I'm interested in workflows and how it translates back to the patient.

At one point early in the morning one of the clinical team members loudly sighed and said "you know what, it would be amazing if we hired a full time transcriptionist or secretary to just type up all this stuff into the eMR". 

That's when the idea hit me. Imagine if there was a seamless, but powerful dictation solution for medical professionals that would import their spoken words into clinical documentation.

 

Electronic Medical Records mean more typing for the clinical staff

Clinical staff have to spend a lot of time typing into computers to ensure their clinical documentation and notes are complete and accurate. The problem is that this frequently translates to more screen-time than bedside-time with the patient. 

 

Improved bedside communications / understanding for patients

If you had a system that captured everything, parsed it into usable notes for the eMR, then there would be a dual-win situation occurring. There would be less burden on being tied to the computer and a greater emphasis placed on holding detailed conversations. Clinical staff may even begin to explain items clearer, in more detail, knowing that eventually it would comprise the medical record. 

This need not only be bed-side discussions or investigations with the patient, but could also be for clinical handover and other important care points.

 

New idea isn't totally new - there are some solutions out there.

A lot of people commented that there are services and products that do this. I hadn't seen or heard about this existing, and I had hoped that my little idea would save some time and bring about some patient benefits.