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Voice Activation in the Emergency Department.

Speech-to-text solution generates a comprehensive, accurate and legible medical record.

During my 15 years of full-time practice in Emergency Medicine, I have had the privilege of caring for many thousands of people. In a rapid and chaotic fashion, I routinely move from patients with sprains and strains to victims of cardiac arrest and everything in between. There are no words to describe the thrill it is to give the critically ill what they need to survive. Nor are there words to explain the tragedy of sudden death.

Yet I do explain. I explain to patients and family members, nurses and fellow physicians, paramedics and social workers and many more important individuals. And, when all is quite literally said and done, I get to commit all this verbalization to paper and ink, better known as the medical record, often just called "the chart".

Medical records serve many crucial purposes. Besides a description of the clinical scenario and therapy, they serve to justify care to insurance companies and managed care organizations. It should be abundantly clear that hospitals and physicians are paid not by what they do for the patient, but how well what they do is documented. Moreover, internal quality of care audits by hospitals rest almost singularly on the contents of the patient's chart. In the event of litigation of course, the quality of the medical record can make you bulletproof or bankrupt.

During a hectic shift in the Emergency Department (ED) then, how does one quickly generate a comprehensive, accurate and legible medical record? The immediacy of handwriting is still practiced by some, but it is usually either quick or comprehensive, rarely both. Besides, some doctors' handwriting (including my own) can defy description. Thus, transcription of the spoken word into a printed document is the only truly viable alternative.

Standard Dictation Downside

I have used standard dictation in the past. The obvious upside is the lack of a learning curve. There are down-sides. First and foremost no matter what device the physician uses, be it stationery or portable, the report must be dictated after the entire patient encounter is over. It is simply unnatural to take reviewable notes verbally, in piecemeal fashion, while waiting for X-rays on one patient, interviewing the next, and running to the radio to give a paramedic orders. Another sticking point with me is turnaround time. Under the best of circumstances, the printed chart can take hours to materialize and not be available to others caring for the patient sometimes until the next day.

Standard dictation also stealthily wastes time. Along with all my clinical responsibilities each shift, I would have waiting for me a stack of day-old charts to proofread and sign. Should an error be found, the error might also be sitting on an unsigned copy of the report already forwarded to the primary care doctor or in the Intensive Care Unit (ICU) as part of an in-patient record. Correcting the ED copy alone is not enough.

Standard dictation also underhandedly wastes staff time. By its nature the insurance information, demographics, vital signs, nursing notes, etc., are separated both in time and physically from the physician's dictation. The multiple pages of each individual component of the emergency record must be correctly collated after the physician's proofreading and signature. If one chooses to collate first, before proofreading and signature, the risk is run of having an unread, unsigned chart that gets filed and perhaps later reviewed by an attorney.

It is for all these reasons I have closely followed the progress of voice activation software for physician dictation. In the mid 80s, I auditioned the DOS version of an early program. Frankly, it underwhelmed me. Slow, staccato, and overly regimented by templates are appropriate descriptions. It simply was impractical.

Fast Forward

Fast forward to 1996: the makers of Kurzweil Clinical Reporter[TM] chose me (who had never owned a personal computer) to be a beta tester of their first Windows[TM] based software for Emergency Medicine physician dictation. It worked well. At this writing, I am using the most recent edition of the product which includes very accurate free-text continuous speech dictation and user-friendly templates that help me fly through the dictation process. Let me describe it for you.

I have a standard PC in our department dictation area plugged into nothing but a wall outlet through an uninterruptable power source device, which I highly recommend. At any point in the patient encounter I can go to the PC, voice the patient's name--I have taught the computer common names--medical record number, and dictate my observations. You can integrate your PC with patient registration and have name and record number waiting for you on the computer screen.

During a slow shift--I have a few of those--I generally dictate completed charts. However, when I face multiple patients, each with complicated history and findings, I try to record the history and physical soon after seeing the patient. I end the dictation at that point in time (and voice the time of day) and can return at any time for follow-up notes.

I proofread the chart as I generate it on the computer screen. I sign the chart as soon as it comes out of the printer (on triplicate forms making three copies instantly). The chart travels as a unit; there is no post-visit collation time.

Immediate Medical Records

These immediately available medical records are put to good use. Resident physicians admitting patients have a detailed analysis of what they need to know to care for the patient. Nurses use them to call report to the floor or ICU. Occasionally, I fax my notes to the patient's primary care doctor before the patient has had time to arrive home. Coding for reimbursement and billing, whether done using the software or by interface with another system, simply cannot be done any faster. The best part is there is no pile of charts to review at the beginning of my next shift, especially appreciated before vacation time.

There are, of course, weaknesses in any system, and voice activation is no exception. Although with every new edition of software it improves, there is still a very noticeable learning curve. The training process lasts weeks for most, months for some. It greatly helps to have a day of personalized instruction at least twice during this period.

An attitude of determination to master the system is essential. It is advisable to approach the software in the same manner as a teenager playing a new video game. You will be frustrated; you will lose a few rounds. As you keep plugging away, however, you will begin to see how the system, with all its rewards, can be used to help you do your job faster and better. You will eventually find voice activation as familiar and useful as your trusty stethoscope.

Should you need any final convincing about the superiority of computerized dictation, compare the cost of voice activation with standard dictation. So called "24/7" transcription is achievable using available software at a small fraction of the cost of a part-time human transcriptionist. Voice activation quite literally pays for itself in short order and will undoubtedly add to your bottom line.

Richard P. O'Brien, MD FACEP, is an Emergency Room physician at Moses Taylor Hospital, Scranton, PA.

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Title Annotation:Product Information; voice-activated medical records systems: Kurzweil Clinical Reporter
Author:O'Brien, Richard
Publication:Health Management Technology
Geographic Code:1USA
Date:Aug 1, 1999
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