For the Record

Voice recognition software can simplify EMR practices

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Steven Schiff, MD, has been a practicing clinical cardiologist for 26 years. (Orange Coast Memorial Medical Center)

Sounding Off on the Spoken Word

In healthcare, the accuracy of speech recognition has made significant advances over the past few years, due to the development of specific vocabularies and models related to clinical speech.

Simple voice-to-text software has had a positive impact on physician efficiency with entering data. Pittsburgh-based M*Modal’s proprietary Conversational Documentation Service (CDS)
transforms conversational speech into

meaningful, usable clinical information. Speech understanding is the natural evolution of speech in healthcare.

CDS transparently captures clinical facts and physician orders from conversational speech without making clinicians change their normal dictation style. Notes entered by a clinician conversing with an EMR through a microphone or phone immediately become validated, interoperable clinical data that can populate an EMR.

Speech recognition technologies have helped increase the efficiency of clinical documentation processes. These benefits have been transparent to most healthcare providers until recently, as speech recognition was applied on the “back end” of the process, often without the speaker’s awareness in order to increase efficiency. But more recently, the technology has been applied on the “front end” where clinicians can see the results of their efforts and experience the benefits of increased productivity.

CDS and its capabilities to understand speech are built on HL7’s Clinical Document Architecture (CDA), which allows M*Modal to integrate existing clinical information from an EMR with
pre-defined templates based on the type of condition, procedure, or patient encounter being documented. As a result, this process creates efficiency by re-using data and allowing providers to focus on the important, differentiating details of a case. In addition, CDS feeds back information to the provider during documentation by applying physician, enterprise, or evidence-based rules to ensure complete, compliant clinical documentation.

A provider-validated CDA document is interoperable with other clinical systems and can be used as a medium for healthcare information exchange and other downstream processes, such as
regulatory reporting, billing, and population management.

On the horizon are applications based on the ability to discriminate the speech of multiple speakers having a conversation, and applying an understanding of that discussion to draft a clinical document of the encounter. The convergence of video and speech processing, and real-time data collection from medical devices offers the potential to create an environment in which a visual and sound recording of an encounter or procedure, along with time stamped real-time data, could drive clinical documentation tailored to the role of each participant. The information can also be available immediately to patient at the conclusion of the encounter. With such a process, you could capture administering medication, adjusting an IV pump, and documenting weight or blood pressure.

– Taras Silecky is with M*Modal’s business development department in Pittsburgh.

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Handwritten patient medical records were born in the 19th century and it seems they have remained almost entirely unchanged since then. Meanwhile, medical care continues to evolve, increasing the need for legible and precise medical histories.

At its best, the written chart is an excellent document that provides a clear record of a patient’s clinical course. At its worst, the chart is a disorganized, illegible collection of papers where information can be difficult to locate. Handwritten charts are cumbersome to reproduce and transfer, and collecting data from many patients can be a nightmare.

Computers have had an impact on patient medical records, just as they have influenced every aspect of modern life. Medical professionals have been slow to accept the digitization of charts due to the profession’s generally conservative attitude toward adopting technology, costs, and the complexity of the task. Adoption is lagging at a time when medical billing and payments are almost universally electronic. This trend has prompted the federal government to provide stimulus money – with the threat of penalties later – to push the project of electronic medical records (EMR) forward.

Adapting to Change

I have worked in hospitals that have transitioned to electronic documentation and been involved with a practice that was an early adopter of an outpatient EMR system. I have experienced the benefits and challenges that accompany this dramatic change in not only documenting care, but also the mechanisms by which care is provided and communicated.

When considering the conversion, the advantages outweigh the challenges. With EMR, information is legible. Computerized entry of medication and other orders virtually eliminate errors caused by illegible writing. Through systems of alerts, pre-set standards, and drop-down lists of choices, errors can be significantly reduced.

In addition, patient charts are always available to doctors and nurses, regardless of their location. Once charts are on the server, the number of authorized caregivers who can simultaneously log on and view it is unlimited. EMRs are also transferable and easily accessible on the ward and from remote locations.

However, the challenges are not small or trivial. Due to a chart’s intricacy and the various roles it plays in patient care, the programs that allow the required accuracy and flexibility can be complex. Getting everyone in the healthcare environment to learn and support such a system can be demanding, and implementation failures can accompany change.

Providing proper training and convincing mid- and late-career physicians to invest in EMR can be daunting tasks. Ultimately we will overcome the hurdles, and medical charting, like everything else, will move from paper to computers.

Incorporating Details

Physician progress notes can be problematic when facilities transition from paper to electronic medical charts. From the outset, physicians need to agree on the critical importance of such notes. Medical records must tell a patient’s tale and physicians must assess the significance of that story. A discussion and plan for a work-up and treatment must also be documented.

Simplified point-and-click or drop-down menus to create notes cannot communicate the complexities of patient histories. It is unrealistic to think that all medical professionals can become stenographers when meeting with patients. It may take decades for typing to supplant writing as the primary means of communication between doctors, nurses, and other healthcare professionals.
Yet with EMR becoming the new standard, how will physicians incorporate their progress notes?

The solution lies in using voice recognition software. For the last three years, I have been using Dragon Medical’s voice recognition software to create chart notes, write letters, generate reports, and input text into my EMR. My dictation costs are now nonexistent. I started with Dragon Medical’s v.8, and moved through v.9, and v.10. At this point, I cannot imagine returning to typing my notes.

Dragon functions at near real-time speed and allows me to add information to a chart while meeting with patients. I often create notes with the active participation of patients and family members.

When the note is complete, it is faxed to the referring doctor. An additional copy is printed out and given to the patient as they leave the office. The notes are largely error-free and immediately available in the chart. The timely process of reading, correcting, signing, and mailing is no longer necessary. Most importantly, the notes can be highly descriptive, which captures not only the raw facts but also the nuanced details that are unique to a particular patient.

An example of the following unedited, voice-recognition generated note shows its usefulness: “The patient is here today to follow up on her symptoms of leg, and occasional arm weakness. In the past two months she says her symptoms are better. She does still, however, get episodes where both legs become weak, causing her to walk with a shuffling gait. Also, sometimes her arms get weak. She does not describe typical claudication related to walking or exertion. She believes that the symptoms occur most frequently if she gets a poor night’s sleep or is otherwise fatigued. The symptoms are not compatible with obstructive arterial disease.”

I cannot imagine a medical record environment of any kind that would not allow for these types of notes. Voice recognition software will allow EMR to realize its full potential. In the end, the results will improve patient care and lower costs.

– Steven Schiff, MD, has been a practicing clinical cardiologist for 26 years. He is medical director of invasive cardiology and chair of medical infomatics at Orange Coast Memorial Medical Center in Fountain Valley, Calif. Direct questions and comments to editorial@rt-image.com.