Palomar Health patient stories come alive in the EMR with less work
“I want to thank you. You have given me back one-and-a-half hours of my day,” said Richard W. Moon, MD, a physician at Palomar Health - a health system providing acute, sub-acute, ambulatory, and home health services to 795,000 residents of Inland North and San Diego counties. Moon was not lauding a reduced patient load or shorter commute, but the impact of next-generation documentation and voice recognition solutions that help physicians create more holistic stories of patients, their needs and the care they receive – within the EMR and with less time and effort. The word spread quickly about the benefits of the new technology – more than 100 physicians across multiple sites and departments adopted the new solutions within days of availability.
Cerner’s Dynamic Documentation™ was designed with and tested by physicians and allows the physician to document directly within his or her workflow. Nuance Dragon® Medical Edition is a voice-to-text conversion software that works with Dynamic Documentation to help clinicians create fast, accurate notes which tell the patient’s story. By using these solutions in tandem, the right information is captured at the right time, and notes become a byproduct of patient care. The intuitive design allows physicians to easily insert relevant information and narrate patients’ stories in rich and meaningful language without disrupting their workflow.
The Palomar Health team chose to eliminate handwritten progress notes on the first day of go-live across its three campuses. Notes were replaced with Dynamic Documentation and Nuance Dragon with key features such as auto-text, chart data and voice recognition. Physicians can customize the user interface to bring attention to the information they find most important, while still including chart data as a reference. Auto-text saves time by allowing physicians to easily populate long documentation and modify a patient’s condition, while chart data – such as allergies and problems – is automatically incorporated into the note or quickly added on the fly from other areas of the chart.
Physicians no longer have to block time for data entry after the patient visit. Instead, they can quickly create notes during patient care. As Moon stated, “This is now more time I can spend back with my patients, their families, my nursing and case management staff, and my family. Thank you for all of this work.”
A recently released feature for Dynamic Documentation allows physicians even more flexibility in how they document through the use of tagged items. Instead of pushing all chart data into the note, physicians can tag and include items relevant to that patient note. Tagging will further help physicians create more relevant notes of manageable length as a byproduct of the care process and aid in the prevention of note cloning by attributing each piece of information added with tags to its original source.
While physician efficiencies and documentation quality drove adoption of the new solutions at Palomar Heath, the organization also realized a number of operational efficiencies. For example, Palomar Health reduced its transcription costs through the voice-to-text capabilities. In addition, when physicians document during the initial encounter in real time, it supports more complete documentation leading to more accurate coding. This means fewer back-end corrections; the corrections and the expense of back-and-forth communications related to those corrections reduced coding operation costs. Precise and complete documentation also supports proper encounter coding to justify correct payment of services.
By capitalizing on the expanding capabilities of medical technologies, physicians are moving away from their computer screens and next to their patients. All this while reducing operational costs. A true win-win.