For HTN Now: Digital Primary Care, we were joined by Jan Donnelly (Business Development Manager at Dictate.IT), Dr Senad Telalbasic (GP, Specialist in ENT Surgery and Medical Advisor) and Professor Vivienne Harpwood (Professor of Law at Cardiff University), for a discussion on the role of digital solutions in primary care documentation.
Jan began by sharing the key message of the webinar: that medical dictation is more than just the correspondence or secretarial workflow.
She noted that legacy systems are still being used in many surgeries, but as times and technologies move on, so do processes.
“At Dictate.IT we have a mobile phone app called Swift; ,” Jan said. “It works with EMIS or TPP and others, and it works from anywhere at any time. Within seconds, transcribed dictation would go back to our web portal for the secretary to pick up, fully formatted. So all they have to do then is manage this correspondence. This saves a lot of time for the secretarial team, so they can use that time on other things.”
Another key service, Jan continued, is Dictate.IT’s Live system. “This is a clinician administration tool provided in the form of a desktop or mobile app. It can manage everything that would normally be done through a person typing – anywhere they can put the cursor, they can dictate. They can dictate into the clinical system, into Word, email and apps. There’s also a canned text feature that enables a set of dictation to be used repeatedly.
“It’s designed to save you time, but also allows you to capture as much information as you need in every instance of your working day.”
Dr Senad Telalbasic on documentation in primary care and the role of digital dictation
Senad began by noting that dictation has already evolved over the years, from writing notes by hand to using a typewriter to using a computer and electronic care records.
“Now we have a possibility to document with self-learning programmes and software, which adapt to the user,” he said. “This software records what was said accurately but doesn’t take as long, so there’s a lot of time gained. For me, this ability to dictate any encounter I have with a patient, in a very busy environment, is invaluable in my every day work.”
So what does consent really mean when it comes to GP consultation?
“People often connect the word consent with surgical consent or consent to do something which explicitly needs to be discussed,” Senad said. “In the world of primary care, every time I speak to someone or someone speaks to me, or information is exchanged, a decision has been made. The patient decides, based on that contact, what they are going to do next. People consent in every single encounter to do something or not to do something, and that is a key point in this discussion.”
Additionally, Senad said, it’s important to remember that “the extent to which medical staff document information often depends on the available time they have and on the perceived need to document; what they think needs to be documented.”
Senad shared purposes for documentation: to capture the quality and quantity of consultation in a way which can be used to describe, exchange, provide handover for issues such as annual leave or sickness leave, future-proof (which is especially important when considering that patients will soon be able to view their own records), and/or understand the previous course of action.
In terms of approach to documentation, Senad noted that it varies between healthcare professionals and working styles, with some preferring to type as the patient is talking, some typing up notes when the patient has left, and some using dictation tools.
“There are numerous encounters with patients and other professionals in a regular working day in primary care,” said Senad. “Some of these encounters will be digital – an exchange of written information – and some are through telephone calls, whilst some are face-to-face. Each one of these needs to be documented as accurately and comprehensively as possible, depending on what has been discussed. Not everything needs a lot of detail, but some things do.”
Senad touched upon the constraints on documentation. “The lack of time is a factor,” he said. “Lacking tools can be a factor for some as well. Not everyone has access to something like a digital dictation tool. Also, lack of awareness for the need for proper documentation can be a constraint, which ties into a lack of awareness for the consequences of poor and insufficient documentation. Full awareness requires some medical legal knowledge as well as medical knowledge in general.”
Next, Senad moved on to discuss the use of modern technologies in primary care.
“One of the main draws of digital dictation tools, for me, is that tiredness doesn’t become an issue – the quality is always there,” he said. “They hear every word and write it up exactly as it should be. They don’t get tired as the day progresses.” Senad noted that he finds this particularly useful as English is not his primary language. “If your medical staff come from a variety of linguistic backgrounds, this is quite important because it makes it easier to document things – they are transcribed in English irrespective of what the native accent may have been.”
Senad summarised the benefits of using a digital dictation tool:
- increased quantity and quality of written content, produced in less time than typing would require
- saves time for staff which they can use elsewhere
- can be used for all types of communication and documentation
- supports medical legal needs
- allows documentation into notes within work outside of surgery
“Is it a perfect tool?” Senad asked. “No, you’ll sometimes spot a word or two that hasn’t transcribed properly. But it’s fascinating to see how the software is learning; with time there are less and less mistakes, and less need to polish things up. Even though I need to return sometimes to correct something, it’s still a huge time saving and efficiency improvement.”
Digital dictation tools can be used for medical notes; internal and external communications such as emails or patient text messaging systems; and for generating different types of medical written materials such as reports.
They can be used by a wide variety of medical professionals: GPs, nurses and district nurses, physiotherapists, paramedics, pharmacists and staff in all community-based primary care services.
“I see digital dictation is a significant evolution of documentation possibilities,” Senad said. “It improves quality as well as quantity, and it gives me some of my time back.”
Professor Vivienne Harpwood on creating a pathway for capturing meaningful and key information
“I’m going to talk about consent to treatment, why good consent is important, and how good consent is informed consent,” said Vivienne.
Vivienne set out how the law on consent has changed; new emphasis has been placed on informed consent, specifically, since a Supreme Court ruling in 2015. “It is very clear that consent must now be a shared process based on honest conversations between clinician and patient,” she said. “The emphasis is on the need to support the autonomy of the patient.”
Doctors and clinicians need to have knowledge and understanding of the current law, Vivienne continued, to enable patient trust – and to save the NHS money. In 2019-2020, compensation payments and costs in claims involving failure to warn amounted to over £415 million in England alone.
Vivienne highlighted ‘the personalised approach’, or patient-focused legal principles. “The doctor or clinician taking consent from the patient needs to try to understand what is important to the individual patient,” she said. “What are the material risks to that patient?”
Obtaining properly informed consent involves spending time to find out what matters to the patient, which can be difficult for time-stretched healthcare professionals; ensuring sensitivity within the discussion; providing clear explanations to patients; and understanding the individual patient’s perspective.
“The making and retaining of detailed records and consultations is vital because it’s important to be able to demonstrate that the patient has been given that information, that they have understood it, that they’ve been given enough time to ask questions, and that the clinician has allowed the patient time to reflect,” said Vivienne. That can involve taking information away, she added, such as notes which can be shared with their family.
“The evidential aspect of this is very important because failure to observe legal principles could result in a claim for negligence.” Vivienne pointed out that there could also be the possibility of a complaint being made to the GMC or the doctor having to appear before an inquest to be questioned about what happened in the event of a death. “These things can be extremely stressful – I’ve practiced as a barrister and I’ve observed how difficult it can be, even for the most confident of people. So it’s vital for doctors to keep accurate and detailed notes, in some form, of all consultations. Consent is an issue, as Senad said, in virtually every situation and every consultation.”
Vivienne shared that the best evidence for legal purposes is contemporaneous written evidence.
Next, Vivienne shared a checklist that is useful to obtain informed consent:
- check that the patient can hear and understand you
- explain to the patient what the diagnosis(es) is/are
- give clear and simple information about the risks of treatment, considering factors likely to be significant
- ensure the information covers the benefits, harms, material risks, side-effects and likely outcomes of each treatment, including waiting or doing nothing
- check that the patient understands the information
- if the patient is having difficulty understanding, try to use diagrams or printed information; check again that they understand, and record actions in the notes
- if the patient might not have capacity to consent, follow the guidance in the Mental Capacity Act and make an effort to involve the patient in the decision
- give the patient the opportunity to ask questions and ensure they are answered clearly
Vivienne finished by bringing up the COVID-19 UK public inquiry. “Among those who will be called to give evidence to the inquiry are doctors, hospital doctors, GPs who have been treating patients in care homes and so on. Evidence is currently being gathered and stored. These public inquiries come along from time to time, so it’s another reason why it’s very important to be careful about how things are documented, along with the importance of keeping that information in a safe place.”
Dictate.IT’s solution
“Having heard about the need to save time and capture evidence with clarity, what we’ve done at Dictate.IT is develop the systems using artificial intelligence to aid clinicians to do this,” said Jan.
She shared how Dictate.IT software integrates with any clinical system and is cloud-based, with no specific hardware requirements. Dictation is 99 percent accurate and analysis shows that it can save up to two hours per day per clinician.
More information can be found on the Dictate.IT website.
At this point, questions were taken from the webinar audience; this section can be viewed at 35:23 on the video below.
Many thanks to Jan, Senad and Vivienne for their time.
