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Computers Like PACS, speech recognition is contributing to the future of digital medicine outside of the radiology department and imaging center. Speech recognition (SR) technology in the healthcare arena was introduced in the early 1990s. While there was excitement about the potential of replacing handwritten notes and simple dictation for medical records, the expectations exceeded performance, and healthcare facilities adopted something of a “once bitten, twice shy” attitude. But SR is widely used in radiology—where a relatively limited vocabulary and high percentage of normal exam reports improve physicians’ ability to use it productively. Because SR’s overall introduction wasn’t as successful as hoped, healthcare facilities have been somewhat reluctant to give it another try—until recently. Improved SR technology and the national goal of an interoperable electronic medical record (EMR) by 2014 have sparked interest in digital dictation and transcription. Technology has evolved to the point where SR can now be used to shuttle the narrative, structured, and encoded information through PACS, EMR, RIS, and other health information management (HIM) technologies. Digital technology facilitates improved decision support, reporting, and information sharing. Done properly, it provides a win-win-win situation for doctors, healthcare facilities, and patients. “Historically, [SR has] been disappointing because it couldn’t deliver on expectation,” says Nick van Terheyden, MD, chief medical officer at Philips Speech Recognition Systems in Washington, D.C., who likens the former expectations to a Hollywood notion reminiscent of old sci-fi shows. “When Philips introduced SpeechMagic in 1993, there was an overwhelming response, but because it was still in early stages, the results were disappointing.” He noted, however, that during the past 10 years, there have been great improvements, and he believes the technology has reached a “tipping point” as far as benefits and efficacy for EMRs. SR’s Resurgence The EMR is a critical piece of technology that can corral patient data into one complete record. Implementation of it, however, is often difficult for financial reasons, as well as because of resistance from physicians who fear substantial interruption in their workflow. But according to Eric Fishman, MD, founder of EMRconsultant.com, the EMR acceptance rate “goes up astronomically when physicians know that SR will be part of the implementation.” Thus, in an effort to keep pace with the information overload created by the need for strong documentation, healthcare facilities are once again turning to SR to increase productivity and, in the long run, improve overall patient care. Implementing SR With the EMR “There is no one perfect solution,” says Fishman. Finding technology that works best for an organization can include using a combination of dictation, SR, templates, and transcriptionist/editors. Kathy LePar, RN, MBA, a senior manager at Beacon Partners in Boston, has guided many healthcare organizations in the search-and-selection process for SR and EMR technology. LePar, who has also helped implement the technology, has seen its prevalence rise during the last several years. “Many of the software vendors demonstrate the use of it for physician practices with ambulatory EMR applications,” she says. Paul Egerman, CEO of eScription Inc., a Needham, Mass.-based company specializing in background SR technology for medical transcription, believes that SR’s two main roles are to reduce the costs associated with transcription, which can be substantial, and standardize EMR documents so they look the same. He says that once the documents are standardized, it becomes easy for physicians to extract the data they need in making patient care decisions. Carle Clinic in Urbana, Ill., is a facility that has successfully made the change to SR technology. Tricia Truscott, MBA, RHIA, CHP, Carle Clinic’s HIM director, was directly involved in the move to SR and the facility’s quest to make medical record improvements. “We were moving to an EMR and needed to find a way to capture the information that was currently in handwritten notes, which meant moving to full dictation. But the cost was staggering,” she says. With 330 physicians in 11 locations, Carle Clinic moved to dictated notes to capture information for its EMR. At the same time, it decided to switch to SR technology in an attempt to stem the huge costs associated with dictating each patient note. On a recommendation from its chief information officer, Carle Clinic chose a software solution from eScription. Because physicians were dictating more notes—notes that were formerly handwritten—Carle Clinic found itself in a situation where the transcription volume nearly tripled, from approximately 15 million to 40 million lines per year. As a result of the SR implementation, the average transcriptionist’s productivity increased by roughly 90% because the new model automatically produced accurate and formatted first draft documents from clinicians’ dictations, which the medical transcriptionists reviewed and edited. In turn, the productivity gain lowered transcription costs. Moving to background SR improved Carle Clinic’s ability to handle more volume, as well as significantly reduce costs. Changing to the eScription technology has also provided consistency in the EMR. Previously, doctors used different templates for straight dictation, but now they work on only a few consistent templates. To date, the information is structured but not discreet, so Carle Clinic is not creating reports from the information or using data fields. Fishman sees this as the way most facilities currently use SR: using the dictation for parts of the record (eg, the history and final assessment) in combination with the templates to fill the diagnostic information, which he says creates a good EMR. With formatted speech data from physician notes, radiologist reports can be stored in the EMR with DICOM images and billing information for a complete record—and hopefully interoperable records some day. Radiologists also can benefit from an EMR by having access to the record before they interpret a study. Access to physician notes and patient history through the record can help a radiologist interpret a study and prepare a report. Additional Applications Michael Finke, CEO of M*Modal in Pittsburgh, agrees: “You want structured and encoded data rather than simply a narrative.” For optimal results, Finke refers to using “speech understanding” rather than simply SR. By “typing with your tongue,” as he calls it, you capture the intent and meaning of the physician, which can be put into a meaningful format. Egerman, however, disagrees that an EMR must contain only objective data. He believes that a balance of textual and objective data can be the most valuable, as there is always anecdotal data from a patient consultation that can’t be captured on a typical “point-and-click” screen that physicians use. He points out how a patient’s social situation is an important aspect that can’t always be captured in the objective data. “For example, a healthy, 96-year-old woman may be at the physician’s office for her yearly check-up,” says Egerman. That noteworthy anecdotal data is important to be aware of, but, nonetheless, may not be included on a physician’s transcript if only EMR objective data is used. Possible Pitfalls “Physicians are so comfortable with SR and the dictating process that, oftentimes, the narrative documentation replaces the point-and-click process of entering data elements, which is necessary to derive outcome data,” says LePar. Many programs already have the capacity to extract meaningful data embedded into their systems, and therefore, it is important to use the narrative fields in conjunction with inputting the data points, she says. Egerman also mentions that SR on its own is simply a technology that should be used as an aid in working toward a complete EMR. “SR is a technology just as a database or keyboard is a technology,” he says, that when used together, they make the EMR data valuable. Improving Patient Care Because information is documented immediately, patient information can be sent in real time to doctors, referrals can be made quickly, and the possibility of medical errors is reduced. From a management standpoint, transcription costs are reduced, and billing can be done in a timelier manner because documentation is completed sooner. “To really get to value, you need to understand what physicians dictate. If a physician wants to take actions [regarding a patient case], the EMR must describe the content in a structured way,” says Finke. With M*Modal’s speech understanding technology, the benefits flow directly from maintaining the same workflow process but repurposing it for something of bigger value to achieve better results. “Nothing changes except the additional benefit of being able to use data to improve patient care,” says Finke. SR, when integrated into the EMR, “ties it back to clinically actionable data,” says van Terheyden, and can tie it in with clinical coding. He believes this is the future of SR because it drives actions that physicians want. It also keeps physicians up-to-date on the most current information, potentially improving patient care. Benefits to Healthcare Organizations At first, physicians may view integrating SR technology with EMRs as a cost because it appears to take more time. However, reports are actually turned around more quickly and have better data from which to draw patient care information. In addition, because patient information is delivered to the EMR more quickly, physicians can bill almost instantaneously. “The reality is, you have to pay bills, so now you don’t miss any information and get fair compensation for work done by capturing it at point of care,” says van Terheyden. Also, healthcare organizations can add monies to their coffers by using voice recognition to negate transcription costs associated with unnecessary text. “Across the whole of a hospital, they can expect a 30% to 40% savings over using conventional dictation and transcription to text,” says van Terheyden. For transcriptionists, or “revisionists” as Fishman says they’re sometimes called, background SR technology allows them to become medical language specialists, a role in which they validate the text’s accuracy. Evolving Process “I see it being used much more frequently than in the past. This technology is what many of the physicians are requesting,” says LePar. “The EMR is a workbook for a physician,” says Finke. “It serves two main purposes: administrative, as well as a clinical data repository.” “Speech recognition, when combined with the EMR, provides key input in successful patient care,” says van Terheyden. “It doesn’t completely solve the problem, but it is an essential piece of the puzzle in conjunction with other facets of healthcare management. It’s a definitive part of the solution.” “SR on its own is a great technology tool. It’s a piece of the puzzle, but an important piece of the puzzle,” adds Egerman. — Annie Macios is a freelance medical writer
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