The first-ever research into the completeness and accuracy of medical records

Fred Brabrant, Nuance
Fred Brabrant, Nuance

When buying a used car, we’re always urged to check its service history. It tells you whether the car has been serviced according to the manufacturer’s schedule, whether it’s been the subject of a recall, whether it has had any advisories on its MOT and how often consumables like brakes, tyres, the exhaust and the battery have been changed. The service history tells you as much about a used car as the condition of its body work, how well it drives whether you’re buying it from Royalty or ‘Arthur Daley’. But while it may seem that we have grasped the concept that consistent documentation assures consistency and continuity, there’s one critical area of our lives where documentation is constantly getting derailed – our medical health records.

While understanding the true story of a person’s health is increasingly critical, today it is also more complex than ever before. That’s why we commissioned independent research company Ignetica to conduct a study entitled ‘The Clinical Documentation Challenge’. This first-of-its-kind research uses the ‘Business Value of IT’ methodology to identify, measure and monetise the value of clinical documentation challenges and it is the first report in the UK of its kind to lift the lid on the impact of inaccurate and incomplete clinical documentation on patient care, clinicians and Health Trust operating costs. It focuses specifically on a comprehensive map of core clinical pathways for acute providers, identifying the many different clinical documentation types.

To ensure we gained a full insight into the medical record challenge, the research includes interviews with CCIOs, as well as perception surveys undertaken with doctors, nurses, therapists and allied roles from four acute trusts, thus reflecting the span of acute care across NHS England. Given how critical the accuracy of your medical health record is to your treatment and long term well-being, the results are concerning. For instance, the research found that in 27.4% of instances of reviewing clinical documentation, the required information was not available or had insufficient detail/clarity at the time required. That means decisions about treatments are potentially being made without the clinician having a complete picture of the patient’s medical history; the consequences that could result from that are worth thinking about.

The study also revealed something else that’s quite telling. Patients (and in some cases, clinicians) often bemoan the fact that appointments often feel rushed; this is no surprise given that the survey found that 50% or more of a doctor´s time is spent on clinical documentation processes. That’s a considerable amount of time that should be dedicated to patients, and not admin. Furthermore, the research was able to put a figure on the value of time searching for information. It put this at £19,474 per annum for senior doctors; that is an inexcusable figure given the regime of stringent cost-cutting across the NHS.

It’s my belief that the study’s publication comes at a critical time for healthcare providers in England. Many Trusts are of course on the cusp of making significant technology investments in Electronic Patient Records (EPRs) and other e-health initiatives in order to boost productivity and to realise the vision of a paperless NHS by 2018, while ensuring that patient and care records are digital, real-time and interoperable by 2020. Looking ahead then, patient information will remain heartbeat of the healthcare system and accurate patient information is what ultimately enables hospital and health systems to provide better care.

But will the promise of EPRs actually improve the quality of clinical documentation, which, arguably is its raison d’etre? To answer that question, you have to consider what’s the best method for

entering patient data into an EPR. While the keyboard and mouse will often be the default choice, not all clinicians are trained or even claim to be competent typists.

However, Nuance’s speech-based solutions for Healthcare have the potential to both improve many of the impacts described in the study and drive more value from an EPR investment. In many cases globally, it has been shown that when integrated into the EPR and other clinical documentation solutions, modern and proven speech recognition enables doctors, nurses and therapists to quickly and accurately capture the patient story at the point of care and transform it into meaningful, actionable information. Therefore, speech can improve the completeness and accuracy of clinical documentation and drive the delivery of higher quality care.

As we move closer to 2018, the question you have to ask is this. If we can take so much care over documents that relate to our cars or other goods, is it unreasonable for patients to expect the same level of thoroughness when it comes to their personal medical records?

By Frederik Brabant, CMIO, Nuance Healthcare.