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Speaking of your health record

DSC_0905.JPGThe least exciting part of any job is the paperwork—just ask a healthcare provider. One visit to the hospital can result in pages of documentation, notes written by the clinical staff about you and your treatment while in our care. Imagine a health system that found a faster, better way to get those important notes into your record, freeing providers to get back to doing what they do best: caring for our patients.
We recently introduced a new clinical enhancement, a systemwide transcription software called Fluency Direct. It is a speech recognition tool that works with electronic health records (EHR) to quickly translate speech—known as dictation—into writing directly into the patient’s record. Our providers have been learning to use this tool while also transitioning to our new systemwide single EHR.
“I just transitioned to Cerner this week, and I am so glad I did the training and at least basically mastered Fluency Direct ahead of this change. Learning too many new things at one time is not my best mode,” said Laura Santilli, PhD, who has been with Northern Light Eastern Maine Medical Center for 26 years. “An advantage with Fluency Direct in Cerner, that I did not have in Centricity, is the ability to cut and paste directly out of Microsoft Word, which also means I can post my own reports, versus needing a support staff person to do that.”
Reassured by her training instructor that she probably wouldn’t speak too quickly for Fluency Direct, Dr. Santilli found the change was still daunting. But, the software’s ability to learn a user’s voice and choice of words made it easier each time. Providers can create their own list of commands to do things like insert tables and use replacements under abbreviations. “What I most like is being able to talk quickly with Fluency Direct. The overall process gives me much more control over the time to finalize a report, I do not need to wait for the transcription before I can edit. The timeliness for receiving reports is a big benefit for our patients, as it can have implications on their ability to access services in schools and in the community.”