Every doctor knows that meeting with patients is only half of a physicians’s job.
The other half is doing the hours of paperwork required to document everything.
As part of a pilot program, the Affiliated Community Medical Center (ACMC) in Redwood Falls has been trying out a new system to document doctors’ observations during patient exams.
Meet the new member of the healthcare team: the Patient Document Specialist (PDS).
Under the older system, doctors would either write notes or dictate observations into a recorder while they were examining the patient.
Then, once the patient left, the notes or recordings were typed up by the doctor or sent to a transcriptionist to be entered into the computers later.
“Usually each transcriptionist had two or three doctors’s notes to transcribe, with a 48-hour turnaround,” said Mary Hoffman, transcription manager based in Willmar.
Under the new system, a PDS — armed with a computer on wheels — goes into the exam room along with the patient to note the doctor’s observations and recommendations in real time.
Lisa Schroeder, a transcriptionist at ACMC who’s been trained in the PDS system, said, “It was very different, going from being in the background to being in the room with the patient and physician.”
According to John Wittenberg, site manager at the Redwood clinic, the program was prompted by a combination of increased federal government regulations and a desire to give doctors more free time in the evenings.
“It gives a better work/life ratio for the doctors. The industry is seeing a lot of doctor burn-out these days,” said Wittenberg.
He added, “One doctor said to me, ‘I went to school to learn how to make medical decisions, not to talk into a microphone or type notes.”
The Redwood Falls branch of ACMC began exploring the PDS system in summer of 2010.
“Emergency rooms in larger systems have been using it, and Dr. Medrud met some doctors in Watertown, South Dakota, whose whole clinic was set up for it,” said Wittenberg.
“I gave that clinic a call and said, ‘So, how did you do that?’ They said it was seamless for them, documenting in real-time what the doctor would have dictated instead.”
Currently the ACMC system has five trained PDS technicians, most of them in Redwood Falls.
Advantages of the PDS system include:
• More free time for doctors.
According to Hoffman, with the PDS system doctors don’t have to take time from their day to go over notes, so they can spend more time with each patient or see more patients during a shift.
Page 2 of 2 - • Faster access to medical records for the next specialists in the line.
“It speeds up the process. If the patient is very ill and needs to be moved to the hospital, the hospital staff wants that info right away,” said Hoffman.
The PDS system also speeds up the time pharmacies get access to necessary information.
The main disadvantage to the PDS system is that some patients just feel uncomfortable having a third person in the room witnessing the exam.
“If the patient wishes, we’ll ask the PDS to leave, but most patients are okay with it,” said Wittenberg.
Schroeder said, “I’ve only been asked to leave once in the last 11 months. For some exams there’s a curtain in the room for the patient’s privacy. It makes the patient more comfortable — and me too.”
After the exam, the doctor and PDS meet to go over the notes and make sure everything was recorded correctly.
Then it’s on to the next patient, without anything still hanging over the doctor’s head for later.