Time for the latest entry in my series of Common EHR Implementation Issues. See also my previous posts on Unexpected EHR Expenses, EHR Performance Issues and a little follow up to avoiding the EHR performance issues altogether.

This weeks common EHR implementation issue is: Inadequate EHR Templates.

Before I begin with the major issues of inadequate EHR templates, it’s worth noting that there are a few EHR software out there that use a different EHR documentation paradigm than templates. For example, some use voice recognition to power their documentation. Others have a system that learns your documentation over time and based on that learning remembers how you want to document certain procedures. Others, use lots of independent documentation methods (one EHR vendor calls them controls – check box, radio button, freetext field, etc.) which can be grouped and used in interesting ways.

However, even with all of the above alternative documentation methods, there’s often an element of templating that’s occurring. They’re PR and marketing people will shudder at the term template, but concepts related to templates seem to pretty much always apply. For example, in voice recognition there’s something called a Macro. That’s basically a template. The EHR system that learns your documentation method is just using your initial documentation in the EHR to create personalized templates of how you like to document. The independent documentation methods often group those various “controls” into groups of common visits. That sounds like a template to me.

I’d be interested to hear of an EHR system that doesn’t use the principles of templates. It is worth noting that all EHR templates aren’t created equal. Some are much more flexible than others. Now to some details.

The inadequate EHR templates shows itself in a number of different ways.

No Specialty Specific EHR Templates – This has to be the complaint I hear the most. It usually goes something like this, “The EHR salesperson said they had templates, but they don’t have any templates I can use.” Did someone say EMR salesperson mis-communication? Yep, happens all the time. Let’s be honest for a second. How could the EHR salesperson know how good their cardiology or neurology templates really are? They just go by what they hear and what they’re told by the EHR company.

Incomplete or Unusable EHR Templates – You may have noticed a subtlety in the quote I put above. At the end the doctor says “templates I can use.” Maybe the EHR salesperson isn’t lying to you about them having those cardiology or neurology templates. Maybe they do have a bunch of templates for those specialties (or whatever specialty that interests you). However, just because they have templates for those specialties doesn’t mean that you’re going to want to use any of the templates that they’ve created.

My favorite complaint is when they say that the specialty templates seem to have been created be a general medicine doctor and not an actual specialist from that field. I’ve heard it far too much not to mention it.

The other major problem with this point is the unique documentation preferences of each doctor. Has there ever been any two doctors that document the same way? We could debate the good and bad merits of such documentation, but the point is that each doctor is very different. Some feel the need to over document the encounter. Other doctors want to just document the bare minimum. Plus, some (purposefully or not) do a terrible job documenting the visit. The templates in an EHR could reflect any of these various documentation patterns and depending on your perspective could mean that EHR has inadequate templates for your needs.

Hard to Modify, Add to, or Adjust – While not specifically an inadequate template, this is an important part of templates. Turns out that if a user can easily modify, add to or adjust a template that is inadequate, you’re going to be a lot better off. Some template systems are like pulling teeth to modify. Others are amazing at how you can on the fly modify the template.

One promise I can make you, You WILL want to modify their templates. I can’t say I’ve ever heard of someone using the templates perfectly out of the box. Well, maybe I’ve heard of one or two using them, but that was when they were complaining that they had no way to modify the things they wanted to change.

Avoiding EHR Template Inadequacies

The best way to avoid this issue is to test drive the EHR software and the specialty specific templates you hope to use. Run through the templates like you’re charting on some common patients. You’ll learn a lot about what templates are available doing this than anything else. You’ll see if the templates are overkill or below standard for your needs.

Another great test is to try using multiple templates for a complex patient. How easily is that done and how well does the documentation display?

Then, during your EHR demo with the EHR salesperson, ask them to modify part of the EHR template they’re using to document. Tell them you don’t like to ask one of those questions, so you’d like to see them remove it from the template. Many are likely to respond, “It can be done, but I’d have to switch systems to do it or I’d have to call in to tech support to make the change.” I think we all know the real message they’re sending.

For those not interested in EHR templates, you might take a second to read Dr. West’s Experience implementing EHR templates in his office.

I recently was asked by Deanna from Mighty Oak to check out a demo of their Chart Talk EHR software (previously called DC talk). It’s always a challenge for me since there are only so many hours in a day to be demoing the more than 300 EHR companies out there. So, instead of doing a full demo, I asked Deanna to highlight a feature of Chart Talk that set them apart from other EHR software companies.

She told me that Chart Talk’s killer feature was its integration with Dragon Naturally Speaking’s voice recognition software. I was very familiar with DNS and other voice recognition software, so I was interested to see if they really could create a deep integration of Dragon Medical over the other EHR software I’d seen that integrated it as well.

I have to admit that I was pretty impressed by the demo. It was really quite amazing the number of things that you could do with your voice in the Chart Talk EHR software. Certainly standard transcription like documentation worked out well in Chart Talk. However, the impressive part was how you could navigate the EHR with your voice. Here’s a demo video that does a decent job illustrating it:

What made the documentation even more interesting (and is partially shown in the above video) is the use of various DNS macros and the even more powerful built in macros for pulling in vital signs, past history, etc. Plus, I like the idea that when you have any issues with Dragon Medical, you don’t get someone at your EHR company who doesn’t really know much about Dragon. Since Chart Talk’s completely focused on Dragon integration, you know they know how to support it properly.

I of course only saw a partial demo of the Chart Talk software. So, I’m only commenting on the Dragon Medical integration in this post. It would take a much longer and more in depth evaluation to know about the other features and challenges to the software.

Plus, there’s no doubt that voice recognition isn’t for everyone. They tell me that some people do the charting with their voice right in front of the patient. That feels awkward to me, but I guess it works for some people. Then, there’s the people who don’t want to go through the learning curve of voice recognition. However, I’d guess that Chart Talk could make a case for being some of the best at teaching people to overcome that learning curve since every one of their users uses it.

I also know that Chart Talk originally started as DC talk. So, anyone considering Chart Talk should likely take a good look at how well the software fits with their specialty. I know the people at Mighty Oak have been making a big effort to work for any specialty. However, like every EHR software out there, they just work better for some specialties better than others.

It’s also worth noting that Chart Talk is a client server EHR. I guess the web browser isn’t quite ready for the processing power that’s required to have a nice voice enabled user experience.

Needless to say I was impressed by the voice recognition integration and how pretty much every command can be performed using your voice. I’d be interested to know of other EHR companies that are striving for that type of deep integration. I’m not just talking about being able to basically dictate into a text field. I’m talking about actual navigating the EMR with your voice.

I’m currently in Denver attending the AAFP conference. So far I’m really glad that I’ve come to the conference. It’s really fantastic to be surrounded by providers. It’s a stark contrast to HIMSS where you’re mostly surrounded by industry insiders and not that many providers. The practical questions the doctors ask are fascinating.

Of course, the comments they make are also fascinating. The title of this post is a comment one lady made in the David Kibbe session on Meaningful Use:
“I use EMR and so I am MY OWN transcriptionist.”

The problem with this comment is that it just doesn’t have to be true. It could be true depending on which EMR software you selected and how you implemented the EMR. However, that’s a choice you make when you choose and implement an EMR without any transcription.

I’ve actually seen a number of EMR vendors that have some really nice and deep integration between their software and transcription companies. There are even transcription companies that are building their own EMR software which obviously leverages the power of transcription.

Plus, many doctors happily use voice recognition like Dragon Naturally Speaking to still do what essentially amounts to transcription with their EMR.

Add in developments around natural language processing and the idea of preserving the narrative that is so valuable and interesting while capturing the granular data elements is a really interesting area of EMR development.

Of course, one of the problems with this idea is that many people like to use the savings on transcription costs as a way to justify the cost of purchasing and implementing an EMR. Obviously, you’ll need to look for other EMR benefits if you choose to continue transcription.

Just to round out the conversation, there are a wide variety of EMR vendors which each have their own unique style of documentation. Part of the problem is that many people don’t look much past the big “Jabba the Hutt” EMR vendors which are these ugly click interfaces that spit out a huge chunk of text that nobody wants to see. There’s plenty of EMR vendor options out there. Keep looking if you don’t like an EMR vendor’s documentation method.

I’ve always been a little bit skeptical about paying the $1000+ for the medical version of Dragon Naturally Speaking. $1000 just seems like a lot of money to be paying for what seems to amount to some medical dictionaries. However, someone who is very familiar with nuance and Dragon Naturally Speaking told me that doctors should really purchase the DNS Medical or they’ll end up dissatisfied.

Well, today I was reading the forum on Amazon for Dragon Naturally Speaking which asks if the medical version is worth it for doctors. The responses generally weren’t worth while, but someone who calls themselves “Pain Doc” suggested the following:

I have used DNS for about 7 years. I started with version 6 as I recall. I had my transcriptionist email me the text files from all my dictations for several years and then I “fed” those to DNS to learn the vocabulary. I then had a very serviceable medical DNS for my practice and an unemployed transcriptionist.

What a genius idea for anyone that’s currently doing transcription. A great way to save about $1000 on software.

Check out the following prices for the various versions of DNS on Amazon:
Dragon NaturallySpeaking 10 Preferred – Currently $151.49 with $50 rebate ($101.49 after rebate)
Dragon NaturallySpeaking 9 Preferred – Currently $92.97
I’m still looking around for the best location to buy Dragon NaturallySpeaking Medical.

Interestingly, this same person quote above also said, “I also upgraded to DNS 10.0 which is a total POS. I am back to 9.0 and wouldn’t recommend 10.0 to anyone.” I’d love to hear more people’s comments on this subject.

In a recent comment by Tom Hamilton, he gave a nice review of a wireless microphone that can be used with Dragon Naturally Speaking Medical. I figured I’d been covering enough EMR politics and implementation lately that it was about time to mingle a little bit of technical content in the middle.

I’ve been told a number of times that if you want to use Dragon Naturally Speaking medical, then finding a high quality microphone is absolutely essential to a quality voice recognition experience. Check out Tom’s review of the Samson Stage 5 Wireless microphone. Wireless is definitely the future.

Samson Stage 5 Wireless Microphone With Dragon NaturallySpeaking Review:<iframe src=”http://rcm.amazon.com/e/cm?t=crashutah-20&o=1&p=8&l=as1&asins=B0002ORQ56&md=10FE9736YVPPT7A0FBG2&fc1=000000&IS2=1&lt1=_blank&m=amazon&lc1=0000FF&bc1=000000&bg1=FFFFFF&f=ifr” style=”width:120px;height:240px;” scrolling=”no” marginwidth=”0″ marginheight=”0″ frameborder=”0″></iframe> 

We’ve just completed Phase 3 testing of the new Samson Stage 5 wireless microphone [$99 on Amazon] and you can read our complete review by clicking Samson Stage 5 Review but the short version is that the new Samson Stage 5 wireless VHF microphone combo includes both a lapel microphone and a headset microphone, costs $99-$105 and is as accurate as our best (starting at $115) theBoom “O” [$149.99 on Amazon] and $145 Sennheiser ME3 wired microphones [$135.83 on Amazon] which cost more and are not wireless. The Stage 5 even includes a three-year warranty. With the exception of end users who require extreme portability, we can’t imagine why anyone would want to pay extra for a wired microphone with a one or two-year warranty. Now everyone can afford to cut the cord!

KnowBrainer, Inc. Support Staff – Tom Hamilton
A Nuance Gold Certified Endorsed Vendor
ALWAYS Ask If Your Speech Recognition Vendor Is Nuance Certified

Thanks Tom for the review.

Check out the following prices for the various versions of DNS on Amazon:


I’m still looking around for the best location to buy Dragon NaturallySpeaking Medical.

In a recent comment, Tom Hamilton from KnowBrainer software sent some interesting insights about using Dragon Naturally Speaking. His observation about more and more physicians using Dragon Naturally Speaking with their EMR or EHR is very true. I expect this trend to continue for quite a while. I don’t know how many times doctors have asked me for this ability. Unfortunately, it is like any software program and takes some getting use to, but those that do get use to it seem to really love it.

Here’s what Tom sent me. I hope it’s valuable for those looking at voice recognition with their EMR or EHR. I always welcome guest posters who want to post information like this to my blog. If you’re an expert at something related to EMR, EHR, or other Healthcare IT related topics, then let me know if you’re interested in being a guest blogger.

EMR Software and Dragon NaturallySpeaking are being utilized together in more practices and by more physicians every year. In light of that fact I would like to offer this information to the curious.

1. If you’re using Vista you should have 3-4 GB of RAM. For an XP platform you will require 2 GB of RAM. The software will run on less but won’t be very as effective.

NOTE: If you’re looking at buying a new computer to use with DNS I would consider looking at ASUS computers. Regardless of what system you by, you want a Core2 Duo 2 GHz or better CPU speed, 2 GB of RAM an XP platform (3 GB on Vista), 2 – 4 MB of L2 cache, a SATA hard drive of at least 100 GB although you may be able get 160 for about the same price. Your soundcard will be important so go with a mid to high end Soundblaster.

2. Unless you’re using a Soundblaster card don’t depend on the integrated soundcard in your computer as it is probably poorly shielded. Get yourself an external soundcard (USB Pod) and use a USB port on the back of your computer as opposed to the front.

3. Here is a copy of the manual we wrote for version 9. It’s designed as version 9.5 upgrade manual but if you are a new user to DNS you can download a full copy manual at KnowBrainer.com. KnowBrainer Manual

4. Here is a copy of the KnowBrainer Quick Tips which is PDF help file for day to day troubleshooting that is updated all the time from questions answered on our forum.

5. Here is a copy of our DNS 9 Review. I think you’ll find it pretty thorough.

6. For research feel free to use the KnowBrainer Speech Recognition Forum as it is by far the largest and most active of its kind.

7. I know there are quite a few users of NaturallySpeaking version 9 who don’t know about the Free upgrade to 9.5. Then there are some that do but don’t have time to find a path to it and worry about difficulty installing it. You should always use the most updated software especially when it’s free. Version 9.5 consolidates the code between version 9 and 9.1 and contains a few minor tweaks. The main purpose for the upgrade is for Vista compatibility. Here is your path and instructions – DNS 9.5 Update Guide

KnowBrainer, Inc. Support Staff – Tom Hamilton
Now Providing FREE (1st 5 min.) Tech Support 615-884-4558
A Nuance Gold Certified Endorsed Vendor
ALWAYS Ask If Your Speech Recognition Vendor Is Nuance Certified

Thanks Tom for the information. I think I’m going to have to “borrow” the dragon naturally speaking software one of my users cast aside and try it for myself.

Check out the following prices for the various versions of DNS on Amazon:
Dragon NaturallySpeaking 10 Preferred – Currently $151.49 with $50 rebate ($101.49 after rebate)
Dragon NaturallySpeaking 9 Preferred – Currently $92.97
I’m still looking around for the best location to buy Dragon NaturallySpeaking Medical.