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Does any EHR system support back-end VR/editing - JanieC

Posted: Jul 05, 2014

I'm interning (in the HIM dept) at a moderate sized healthcare facility that will go live with Cerner in the fall. The dept. head insists (and rightfully so) that she wants her current MTs to have the capability to edit any VR generated documentation through Dragon 360. Cerner is flatly stating that's not possible. That if Dragon 360 is deployed, clinicians/users will edit but that's it. When you read Dragon 360 literature, it specifically states that the VR generated text can be edited by the user or routed to MTs/editors (but I'm not sure if that's maybe just for the individual provider solution).

So I just wondered if ANYone out there is working for a facility or knows of a facility that uses Dragon 360 within their EMR where they are routing VR generated text to MTs/editors for finalization.

I guess in my naivete, I also thought that it was possible to implement a sitewide solution where the MTs (on-site/employed by the facility) could become editors. I work for an organization that uses Epic and Dragon 360. Some docs use the VR and many, many do the "partial dictations" that we transcribe in total. When I asked about editing and the dept head said we didn't have the capabilities, I just thought it was due to the expense...is it truly impossible?

If Cerner tells you no, it probably means no. - Informaticist

[ In Reply To ..]
They know their system, after all. I am not familiar with Cerner, but I can explain why they say that based on what we have.

The systems you are used to have the physician dictate from a phone to a dictation system. That routes the dictation through the VR. The resulting mess is routed to an editor. The resulting reportis routed back to the facility. Only then is it attached to the record, whether EHR or paper, and signed.

When the physician dictates through Dragon as a front-end solution, he is IN the patient's record, not dictating from a phone. He is IN THE REPORT as he speaks. Dragon transcribes it INTO THE REPORT in real time, as he speaks each word, right in front of him. He can edit it as he goes if there are errors. Again, the actual report is live in the record right in front of him. HE SIGNS IT RIGHT THEN. At that point, it is all said and done -- no changes are possible because it was signed.

I addition to that, what exactly do you plan to listen to when you do this "editing"? I doubt if there will be a recording, because ... again ... the voice does not go to a dictation system. It goes straight through Dragon onto the report.

The notion of having your MTs "editing" is actually a little silly. The whole point of front-end SR is to bypass the need for an MT or even back-end SR.

What you WILL need now are documentation auditors and clinical documentation improvement specialists (CDIs). So, what you do is convert some of those MTs to those jobs. And, yes, you can expect to pay them more.

Instead of keeping on with the same old world-view, the new documentation auditors review the reports against facility standards. They can monitor for clarity, etc., but they are not going to be changing things, just reporting. CDIs do more and require formal training, including coding. You can google to see what they are and what they do.

Believe me..I understand how it works - JanieC

[ In Reply To ..]
I am well aware of how Dragon 360 operates within the EHR environment as I currently am an MT at an HCO that uses Epic and Dragon 360. Some physicians use VR entirely (and I do understand that they are able to dictate and edit in real time as it imports into the patient's record), other providers prefer "partial dictations" in which they dictate, we transcribe, then it is imported into the patient's Epic record via Chartscript. We used Chartscript before EHR transition and use it now. Some MDs express a desire to use Dragon, the facility pays for the license, they receive training....and then they return to the straight dictation/transcription model. Are you aware of Nuance who now owns Dragon?....the megacorporation that also is a giant medical transcription service? Hospitals/providers who use their service send "straight dictation/typing" voice files where the MT transcribes without any VR having been employed in the process while the majority of the voice files/reports they receive are the "back-end speech recognition" type in which the MT edits the created text to correct errors, ensure proper format, etc., then the final product ends up being imported into the client's EHR. So you can see my confusion as to why this capability seems to be available when it's outsourced to a service, yet not available when the HCO wishes to have their own staff edit/correct. And I do realize that Dragon 360 and solutions like Cerner and Epic are 2 different entities, but obviously Dragon 360 is an application that does work in the EHR. In the theoretical world, yes...doctors would edit their reports and everything would look just great. In reality, this process not only inhibits their usual workflow (many times it has been pointed out that the MD's time should NOT be focused on performing "clerical-type" duties)and frankly most MDs are not going to "waste" their time properly formatting, punctuating, etc., to aid in clarity of the narrative...and frankly I have caught errors in which the MD just plain makes an error. That's the MT's specialty. And back-end VR, in which you seem to think MTs can be eliminated, is exactly where MTs are utilized in order to edit/correct. I am aware of what CDI and CD specialists do, and some MTs will transition to this, but you actually need BOTH. The HIM director is ultimately responsible for the quality of the patient's documentation. So I completely understand why she does NOT want a world where front-end VR is the ONLY choice for the facility, with doctors creating VR narrative that goes directly into the patient's chart with no intervening "set of eyes" before it becomes a permanent part of the record. I am well aware that at some point VR will improve to that point...maybe. But it's most certainly not there yet. Even when considering just data mining, with the potential future implementation of natural language processing (or "natural language understanding" as Nuance terms it), issues related to unconventional grammar, punctuation, etc., can inhibit its accuracy, which could be diminished or eliminated if the VR-generated narrative is edited and reviewed. I'm not just trying to hold on to a "dying" profession (MT), because I'm near completion of a BS in health informatics...I'm just pointing out flaws in the beliefs that VR is THE solution to get rid of all your MTs, let your doctors dictate and the quality and accuracy of patient documentation won't suffer.

JanieC - Informaticist

[ In Reply To ..]
You asked a question. I answered it. The answer is: No, in this situation it is probably technically impossible, or at least unworkable, to pass the front-end SR product through an MT editor.

This has nothing to do with whether MTs provide value or not, and it was not just my opinion on the state of the MT world. You asked how it worked and I told you.

What, then, triggered such a rant of a response from you?

In the future, if you want people to know everything you already know, tell them. That will save you from anger over being misunderstood because your reader is not a freaking mindreader.

You still don't understand how it works, by the way. The answer is in my first post.

Just found this...so late replying - JanieC

[ In Reply To ..]
I guess my previous post was too lengthy then came across as a rant, so will keep this brief(er).

Nuance/Dragon 360 has a software solution, EditScript which, when reviewing user guide/documentation, seems to offer the capability of sending to editing (e.g., inhouse MTs) prior to finalization of documentation. So not sure why this cannot be integrated into Cerner, Epic, etc., since Nuance products and Dragon 360 can be. Again, a HIM director who is ultimately responsible for quality of clinical documentation oversight should have the flexibility to use her own MT team rather than outsourcing to Nuance, etc., to be edited or to have 100% of dictating clinicians go to VR. So my question: Could this be a viable solution?

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