Doctor's notes get clearer with speech recognition software

Speech tools play role in electronic health record adoption

Speech recognition technology is being linked to an increase in adoption of Electronic Health Records (EHR) technologies in US hospitals, as doctors are finding it easier to build more complete patient records more efficiently than with handwritten notes.

Major Craig Rohan, a staff pediatrician at Peterson Air Force Base, has been using speech recognition for 18 months to keep electronic health records, especially for more complex cases where a detailed set of notes from an examination can help other health professionals involved in the patient's care.

"I'm a big fan of the technology," Rohan said in a recent interview. "It's tough to imagine practicing medicine without it at this point."

Rohan uses speech recognition technology from Nuance Communications and found that when he goes back to the medical record of a child patient long after the first examination, there will be more detail than if he had taken handwritten notes.

"When you read the actual medical record, it is kind of conversational, but it's more complete and lets you know what's going on," he said. "It's actually verbatim."

Many users of speech-to-text technologies have tried the tools to save time, but Rohan said that isn't what matters to him. "To be honest, I'm not sure it saves that much time, but it does mean I have a far more thorough note," which can help patients and hospitals in billing an insurance company and getting proper credit for care.

Rohan said he has found the technology highly reliable, meaning that the words printed are almost always what he spoke into a microphone. He had to train the software for about 15 minutes, using a script with medical language, and he always edits the printed words. "I use a medical version full of snobby doctor words for simple ailments," he said.

Nuance boasts that its software is 98 per cent accurate or better out of the box, but Rohan has found some obvious errors. "The software might substitute a phonetic spelling, so it might come out 'drain rumor' instead of 'brain tumor,'" which is easy enough to check on the edit, he explained.

One big advance with the technology, Rohan said, is the ability to pre-program what is involved with a routine exam. This means that a patient's medical record will have every detail of the exam, which might not have been handwritten by a doctor in a hurry. He described the function as similar to a macro key on a keyboard.

"If I had to do a head-to-toe neurologic exam that includes things we wouldn't normally do, I could tell the software to write out 'neural exam' and it would document every detail," he said.

Aside from such efficiencies, the larger question for Rohan and the medical establishment nationwide is whether EHR is making a difference in health care. Rohan believes there are signs it has, and part of the reason is speech recognition technology. "EHR has done well at my clinic, with fewer kids hospitalized because they are better tracked," he said.

In the case of a child with asthma, for example, many parents might assume that if their child isn't showing any symptoms than he is doing well, but a clinical test of a lung function might show the child needs more aggressive therapy. "The EHR helps us to track patients and use nurses more effectively," he said. "The nurses don't have to read our handwriting and because everyone has quick access to a medical chart, care is more complete."

Rohan said he is aware that some clinics are not as efficient and that civilian doctors don't like using the EHR approach. "The results vary and reviews have been mixed," at least in the several military clinics he knows about, he said.

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Matt Hamblen

Computerworld
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