DRT / Partial Dictation

Discrete Reportable Transcription (DRT)

Freedom of Expression: Physicians prefer the freedom of expression and semantic richness that is only realized with dictation. Discrete Reportable Transcription provides the benefits of transcription with XML-based structured documentation. With Discrete Reportable Transcription, narrative dictation is encoded with discrete data elements that are easily imported into EHRs.

“I’m not a typist, I’m a doctor”

Discrete Reportable Transcription (DRT) helps populates transcribed narrative into specific EHR fields and sections, leading to improved clinical documentation, clinical decision support, and a number of other opportunities to deploy automation with actionable data.

Discrete Reportable Transcription (DRT) solution, integrated with our partner EHR systems, reduces the major causes of slow EHR adoption. DRT accelerates physician data entry time without sacrificing productivity.

For those institutions that have not yet adopted an EHR, Discrete Reportable Transcription provides a document structure that will transfer to EHRs once implemented. Whereas, traditional medical transcription with HL7-based integration just feeds EHR systems with unstructured data as attachments.

Partial Dictation

Partial dictation allows doctors to manually enter certain information (eg, vitals, current medications) while dictating the detail-rich portions of an encounter (eg, family history, medical history, treatment plan). The goal is to allow as many options as possible to meet the needs of each physician—and patient. Partial dictation can help ease physicians into using an EHR because it retains traditional dictation with which physicians are already familiar with. If physicians are all of a sudden being asked to type their own notes, whereas they used to pick up a telephone and dictate for a few minutes, that’s a big change to their workflow and daily habits.
Even with speech recognition, the learning curve is way too high. The voice engines do improve over time. Hence experts say there are several explanations why hospitals may start to gravitate toward a partial dictation model in which portions of the record are dictated in a narrative format.

First, stage 2 meaningful use criteria specifically address and allow the ability to collect both narrative and structured data in the EHR.

The Office of the National Coordinator for Health Information Technology recognizes the importance of both formats in terms of patient care.

Adopting partial dictation also can help ease the burden of ICD-10-CM/PCS demands, which include greater specificity. Templates and drop-down menus simply don’t capture the necessary level of detail.

Incorporating a healthcare documentation specialist as a partner in that workflow process elevates physician efficiency and further enhances the integrity of the patient’s health story.

The integrity of the data as well as the accuracy and completeness of the patient’s story is the most compelling reason for clinicians to have multiple options.