Electronic health records (EHRs) are designed to ensure accurate, current, and complete information about patients at the point of care. Physicians and nurses are always encouraged to perform medical charting as close to the patient as possible. Real-time data refers to the recording of patient evaluations, observations, and interventions and all other types of clinical data as they are generated. Real-time data capture supports informed clinical decision support which improves patient care and safety. Today, there are a vast array of advanced digital tools to capture clinical data and deliver it into the shared medical record. For instance, physicians use voice recognition software to get their speech converted to text in real-time and rely on medical transcription services to get the AI-generated documents edited and reviewed to correct any misinterpretations.
Relevance of Real-time Data Entry in Healthcare
The integration of shared electronic health records enables patients to receive better care as their healthcare providers will have quick and easy access to their records. Timely data entry is important to ensure accuracy in shared patient records. The key benefits of real-time integrated data capture in healthcare are as follows:
- Prevents errors: Delays in data entry can lead to errors in the medical record. The wider the gap between the health event or encounter and data entry, the greater the chances of mistakes and omission of important details. This will lead to incorrect hand-off communications and impact patient outcomes. With real-time data entry, patient results and other information are documented as soon as they are available. As everything is recorded when it happens, physicians don’t have to worry about missing information in the EHR.
- Improves decision-making and patient care: Real-time data enables clinicians to make proper decisions based on comprehensive information. Telmediq references a study published in Nursing Times which found that up-to-date data can help physicians and nurses to spot patterns that show a patient is deteriorating or may have an infection. While some data points may be automatically fed into the EHR, vital observational data from nurses and doctors are not automatically entered. Real-time data entry ensures timely recording of all this clinical data. This will help staff take the right decisions and implement interventions before the patient’s state becomes critical.
- Lowers overall costs: Manual data entry can lead to errors that increase overall administrative costs. Human data entry can lead to errors and correcting them increases the administrative burden. Organizations have to waste valuable time and resources on correcting the mistakes. Automated data entry reduces the time involved in entering, recording and checking information. It also decreases costs on redundant medicaments and prevents costly duplications.
- Improves compliance: EHR data and real-time data entry provide clinicians with a complete view of the patient’s past medical history and present illness. This information can be used by hospitals to assess their compliance with clinical protocols and whether their patient harm prevention alert strategies are working efficiently. In addition to improving care, real-time automated recording of observations, assessments and interventions helps implement staff deployments based on patient needs, and provides a clear data trail during investigations of incidents and complaints, explains Telmediq.
Real-time Medical Data Capture Solutions
A data driven, real-time health system would incorporate different types of solutions to capture data in real-time. Point-of-care technology captures data on the spot and allows it to be shared electronically during patient appointments.Health apps capture key health parameters and transmit them real-time. However, healthcare IT integration is complex. It involves bringing different IT, clinical, telecom, and EMR/EHR systems together to allow information flow. An ideal solution that supports real-time charting, as reported by womenled.org, would feature the following:
- Intelligent field mapping to minimize duplicate data entry
- A user-friendly interface with all data available on a single platform
- Voice-to-text capability to speed up and simplify data entry
- Easy transfer of clinical notes for rapid documentation
- Immediate delivery of critical lab and test results to the right clinician with date, time, recipient, and delivery status
Real-time patient data capture has become increasingly important with the COVID-19 pandemic. Mobihealth recently reported on Coviu, a new app that combines telehealth and remote patient monitoring to help providers manage COVID cases. The app can display health data from bluetooth-enabled medical devices, such as pulse oximeters, blood pressure monitors, and digital thermometers, in video teleconsultations. Clinicians can get real-time measurements while holding a video call with a patient.
Coming to EHR documentation, automatic speech recognition services allow physicians to quickly and easily dictate their notes and get their speech converted to text automatically in real-time. This text can be automatically integrated into EHR systems.
While such automated transcription tools may have changed the EHR data capture game, accuracy is often a problem. “More or less accurate” is unacceptable in healthcare. Moreover, the software can have problems with jargon and cannot recognize accents and multiple voices. But fortunately, there’s a solution – getting the machine generated text checked by a professional medical transcriptionist. US based medical transcription companies have skilled teams that review and edit automated transcripts to ensure error-free EHR medical documentation.
