Problem: Too Much Secretarial Delay

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Since current electronic health-care record systems are largely text based, there is a large amount of text to be written after each encounter. In Sweden, doctors generally dictate the entry after each encounter, and a secretary then types it out. The same procedure is used for referrals, reports, and letters.

Brevity in notes is definitely something to strive for, but the dictation system lends itself to overly long notations instead. This, in turn, makes the text mass of the EHR grow faster than it otherwise would need to do, a problem I already discussed elsewhere.

Since secretaries are often overloaded with work, it takes a day or two, in the best of cases, before the notes actually show up in the EHR. It is not unusual to see a delay of two or three weeks between dictation and transcription. During that time, work is made more difficult for other doctors and staff, since the only recourse is to listen to an original sound track of the dictation, if you need the information, while it is almost impossible for anyone but a trained secretary to understand the garbled and mumbled monologue doctors are usually producing. It seems that the only thing worse than our handwriting is our dictation.

If the doctor dictated referrals, these also wait for days, or in the worst case weeks, before being sent off. Meanwhile, nothing happens and the patient is left suffering, waiting, and possibly drawing disability from the insurance as well.

The underlying problem here is that the health-care records are text based, due to the lack of a correct analysis of the problem domain. Since the user cannot interact with the object that should have been there but isn't, the "disease", he is forced to describe the interactions with words instead.