The free Dragon Dictation app from Nuance software is probably one of the most useful apps I’ve ever met. It allows me to eliminate all transcription costs and finish my notes, for the most part, by the end of the day. Last Friday, I saw 20 patients (mostly followups) and had no homework for the weekend (although I was humping it all day long, believe you me!). I type in most of the more mundane information during initial office visits with patients, such as the past medical, family and social histories, the allergy and medication lists, physical exam template and management plan.
Thus, 90% of the note is done when I walk out of the room. The dictation I perform is for the history of present illness (HPI), i.e. the patient’s story, and this takes me about two minutes to dictate per patient. Dragon Dictation automates the typing for me and I send the draft to an anonymous email account that I can then immediately use for editing, followed by cutting and pasting into the EHR note. Editing these notes takes about two minutes each since about 90% of the spelling is already correct using this great app.
Recently, I was interviewed for Diabetes Practice Options, and the topic of e-dictation and security came up. Our discussion included how to protect patient anonymity in this process while still gaining the efficiency. One thing a provider can do is use only a single initial from the patient’s name to mark each dictation. Because there are no other pieces of personal information such as dates of birth or social security numbers, anonymity is fairly preserved. Other options include using a number instead of an initial or eliminating this step altogether since it’s usually superfluous for most providers. After all, it’s hard to forget which story goes with which patient if you do your job well and take the time necessary to get to know your patients.