Handwriting Recognition: Why Is It Not the Norm?

October 2017

In this day and age, most healthcare providers have accepted using Electronic Medical Records (EMR) to fulfill a significant portion of their job functions including ordering, electronic prescribing, clinical decision support, and documentation to name a few.  However, it is important to recognize that acceptance does not necessarily equate to successful adoption.  Simply because a provider has accepted documenting a note electronically does not automatically translate to obtaining quality, meaningful documentation without severely detracting from the patient experience.   Nowadays, most providers would agree that they spend more time on data entry in the computer than they do actually with their patients.  The increased computer interaction tends to make it more difficult to maintain consistent eye contact while typing and checking off required fields in comparison to using pen and paper.  This issue has been improved in some cases through the use of scribes and/or voice recognition, but by no means has it been fully resolved.  Additionally, the ripple effect of increased screen time by providers while interacting with their patients is much more visible in certain healthcare settings and specialties than in others.  

One venue in which the patient experience has drastically changed as a direct result of the introduction of the EMR is the ambulatory practice setting.  Here, it is all but expected for the provider to sit across the room from their patient staring at the computer screen while clicking and typing away, with a quick glance to the patient here and there as they ask their checklist of questions.  In addition to the clicks and textual entries that occur while the patient is in front of provider, more often than not the provider will still need to go back to their office after the visit to accurately transcribe or dictate the remainder of their findings. This exercise has become a necessity in this EMR driven workflow as it would be uncomfortable for everyone involved if the provider were to fully dictate the necessary documentation while the patient was physically present.  Imagine if you were a patient and had just interacted with your provider who had spent the majority of the visit staring at their screen, and then just as you anticipated the visit ending, they asked you to stay a few minutes longer and began to dictate the remaining portions of the HPI or assessment.  It is safe to say in this theoretical example that the patient experience would be almost completely disregarded, as it would just involve more computer time for the provider.  Thankfully this has not become a common practice.  It seems that the "new norm" most practice settings have landed on consists of a relatively middle-of the-road approach which burdens the provider with a bit more work after the patient leaves and affects the patient through less consistent eye contact through the clinical interaction.   This raises the question, has acceptance resulted in successful adoption in this instance?  Before this workflow was made electronic due to EMR mandates, the provider would have a paper template in which they would be jotting down notes as they examined the patient while visibly engaging with them.  Prior to either party leaving the room the note was signed and the chart closed.  Why does this seemingly logical workflow have to change completely in the world of EMRs?

Now let us switch over to the behavioral health setting, which surprisingly enough prompts very similar questions as the ones resulting from the examination of the practice setting above.  Here, providers need to be able to maintain eye contact to observe and accurately evaluate the patient during a session.  This non-negotiable directive often leads to good old fashioned pen and paper note taking while with the patient; as clicks and consistent typing would be extremely counterproductive in this setting.  Once the provider is no longer face to the face with the patient, they then can begin the process of translating their written notes into the EMR through transcription or dictation.  During current state assessments or workflow discussions with behavioral health providers, the feedback most consistently received echoes two similar trains of thought, being “this does not work for how we practice” or the all too common “I will do it because I have to, but there has to be a better way.” One has to wonder: why has the healthcare field not taken advantage of all of the tablet technology available with stylus pens and built-in handwriting recognition technology to create a better way of obtaining meaningful electronic documentation while the provider is in front of the patient, without detracting from the patient experience?  It is not hard to imagine what this hypothetical process would entail, as it would simply involve the provider, while in front of the patient, jotting down notes in a prebuilt template using a tablet and stylus while the readily available technology transforms the handwriting into a textual note.  Ideally this process would result in more eye contact with the patient and less after-visit work for the provider.  Just as easily as one can play this scenario out in their head, one can also hear the most common rebuttal of “what if the handwriting is not recognized?”  This response is a moot point as all technology leveraged for new purposes has a learning curve.  Think about what happens today when voice recognition cannot understand what was dictated, the provider will manually reconcile.  No harm, no foul.  It is important to remember that voice recognition software was not perfect when it was first introduced, but significant efforts have been put into improving the technology and look at it now.  If the same amount of time was put into improving handwriting recognition technology within an EMR as was for voice recognition, it would seem to be the best of both worlds. The provider would be able to have the pen and paper feel, the information would be transcribed electronically in real-time, the provider would be able to spend more time engaging with the patient through consistent eye contact, and efficiency would increase as a result.  All things considered, one has to ask why the adaptation of handwriting recognition seems to be continually overlooked in the healthcare field. 

Part of the hesitation of truly exploring this possibility may be related to underestimation of the importance of eye contact between a provider and patient during a clinical visit.  In the grand scheme of healthcare research, this topic has only relatively recently began to be investigated, but slowly more and more conclusive evidence shows just how important it is.   A study published in the Journal of Participatory Medicine in 2013 found that eye contact between a clinician and patient during a clinical encounter, along with other nonverbal interpersonal interactions and length of visit, were directly related to the patient’s assessment of the clinician’s level of empathy and their perceptions of the clinician’s attributes including connectedness.1   The study made very clear that further research in this area is necessary “…with regards to health information technology and clinical system design.”2   Specifically the authors of the study stressed that “[c]linical environments designed for patient and clinician interaction should be designed to facilitate positive nonverbal interactions such as eye contact and social touch. Specifically, health information technology should not restrict clinicians’ ability to make eye contact with their patients.”3

It is paramount in any field that industry professionals constantly look at the current state or best practice of something with a fresh eye for improvement.  This is especially critical in the healthcare field as the stakes are so high.  Something as simple as asking the one word question of “why” can be the tipping point for the first domino of change when it comes to either a research study being conducted or modification in workflow that can have a ripple effect on the patient experience worldwide.

About The Author: Nichole Malone is a highly experienced specialist in the implementation and support of information systems for clinical and ancillary applications who has worked for HealthNET Systems Consulting Inc. for seven years. She has served in a variety of different capacities in MEDITECH Magic, C/S, and 6.x and Epic implementations including strategic planning, coordinating, training, testing, and troubleshooting. She is Epic Beaker Clinical Pathology certified and has experience as a Beaker Project Lead for a large scale implementation. Her well-rounded knowledge base of hospital processes and process improvement strategies adds value throughout all phases of implementations. She has notable strengths in clinical systems, laboratory operations, system integration, application testing, training and process re-design.