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18-10-2012 | Legal medicine | Article

Quality of care drops if doctors dictate


Free abstract

medwireNews: Physicians who predominantly dictate patients' medical notes have worse quality of care than their peers who use structured electronic health record (EHR) documentation, show study findings.

Indeed, the latter form of note-taking resulted in better care quality in measures including blood pressure (BP) and body mass index (BMI) than did dictation or free-text documenting, report the researchers.

A potential solution is to "increase the usability of structured documentation systems so they are more appealing to physicians," say Jeffrey Linder (Brigham and Women's Hospital, Boston, Massachusetts, USA) and colleagues, and make "better use of affiliated staff, such as medical assistants or nurses, to enter critical coded data."

The results emerge from a 9-month study undertaken in 10 US primary care practices, which included 234 primary care physicians who saw 7000 coronary artery disease (CAD) and/or diabetes mellitus (DM) patients.

Quality of care was measured against 15 visit-based variables (two for CAD, six for DM, seven for both) including quality of documentation (eg, smoking status), medication use (eg, antiplatelet), testing (eg, HbA1c ordering), management (eg, BP), and vaccinations.

The researchers found that based on 188,554 notes taken during the study period, 20 (9%) physicians predominantly dictated, 68 (29%) mainly used structured documentation, and 146 (62%) mostly used free text notation.

After adjustment for clustering by patient and physician as well as other potential confounders, quality of care was significantly worse for those who give dictation than for structured note-takers or free-text writers in three quality measures: antiplatelet medication, at 51% versus 59% and 56%; tobacco use documentation, at 22% versus 38% and 36%; and diabetic eye examinations, at 39% versus 53% and 54%, report Linder et al.

Conversely, quality of BP and BMI documentation, and diabetic foot examination was better for structured note-takers than for those who give dictation and free-text writers, at 98% versus 81% and 89%, 40% versus 28% and 35%, and 14% versus 11% and 9%. Influenza vaccination quality was best among free-text writers, at 68% versus 60% for those who give dictation and 64% for structured note-takers.

There was no measure for which those who give dictation had higher quality of care than physicians using the other two methods, remark the researchers in the Journal of the American Medical Informative Association.

"Whatever dictation style physicians use, practices need systems to ensure that critical coded information is captured and deficits in quality are addressed," they conclude.

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

By Sarah Guy, medwireNews Reporter

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