A recent survey of the College of Healthcare Information Management Executives (CHIME) members, including 126 CIOs, shows that while over 82% of participants indicated that their organization is either strongly encouraging and/or mandating for electronic physician documentation for inpatient care; only 18% had implemented the technology. And of those implementing the technology, 55% reported that less than half of their organization’s inpatient, physician documentation is being completed electronically.
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The preferred documentation process used by 42% of respondents was a set of structured inputs using forms or templates. Structured tech and transcribed dictation (29%) and mainly free text entered by the physician (17%) comprised the other cited processes used, along with the 12 percent that selected “other methods” including exploring templates with voice recognition, structured input using forms with dictation and mix of free text with structured text.
The primary tools for physician documentation activities were fixed workstations with laptops and computers on wheels. Exactly half of the respondents use voice recognition software and only eight percent used handwriting recognition software.
In order to increase the implementation rate, some physicians gave advice, along with answering the survey, on how to engage more users. Some of their suggestions were keeping the physicians involved in the development of the tools, and to refrain from immediately requiring implementation. Other concerns were about needing high standards of products and to allow physicians to have ample training time.
See CHIMES’ website for more information.
What percentage of your inpatient physician documentation is completed electronically?
Less than 25%: 33%
What is your policy regarding electronic documentation?
It is strongly encouraged 42%
It is mandated 38%
It is voluntary/optional 21%
What is your approach of documentation?
Mainly structured input using forms/templates 42%
Structured text and transcribed dictation 29%
Mainly free text entered directly by the physician 17%
Other includes: exploring templates with voice recognition, structured input using forms with dictation, mix of free text with structured text.