Abstract
BackgroundClinical documentation has undergone a change due to the usage of electronic health records. The core element is to capture clinical findings and document therapy electronically. Health care personnel spend a significant portion of their time on the computer. Alternatives to self-typing, such as speech recognition, are currently believed to increase documentation efficiency and quality, as well as satisfaction of health professionals while accomplishing clinical documentation, but few studies in this area have been published to date.ObjectiveThis study describes the effects of using a Web-based medical speech recognition system for clinical documentation in a university hospital on (1) documentation speed, (2) document length, and (3) physician satisfaction.MethodsReports of 28 physicians were randomized to be created with (intervention) or without (control) the assistance of a Web-based system of medical automatic speech recognition (ASR) in the German language. The documentation was entered into a browser’s text area and the time to complete the documentation including all necessary corrections, correction effort, number of characters, and mood of participant were stored in a database. The underlying time comprised text entering, text correction, and finalization of the documentation event. Participants self-assessed their moods on a scale of 1-3 (1=good, 2=moderate, 3=bad). Statistical analysis was done using permutation tests.ResultsThe number of clinical reports eligible for further analysis stood at 1455. Out of 1455 reports, 718 (49.35%) were assisted by ASR and 737 (50.65%) were not assisted by ASR. Average documentation speed without ASR was 173 (SD 101) characters per minute, while it was 217 (SD 120) characters per minute using ASR. The overall increase in documentation speed through Web-based ASR assistance was 26% (P=.04). Participants documented an average of 356 (SD 388) characters per report when not assisted by ASR and 649 (SD 561) characters per report when assisted by ASR. Participants' average mood rating was 1.3 (SD 0.6) using ASR assistance compared to 1.6 (SD 0.7) without ASR assistance (P<.001).ConclusionsWe conclude that medical documentation with the assistance of Web-based speech recognition leads to an increase in documentation speed, document length, and participant mood when compared to self-typing. Speech recognition is a meaningful and effective tool for the clinical documentation process.
Highlights
The diagnostic and therapeutic procedures of medical professionals lead to a vast number of observations and decisions, which must be documented correctly to ensure the documentation of the medical course, fulfillment of legal aspects, quality reporting, and billing
The study was not registered in a World Health Organization (WHO)-accredited trial registry since there was no applicable biomedical or health outcome conforming to any human subject or ethics review regulations, or regulations of the national or regional health authority
We conclude that medical documentation with the assistance of Web-based speech recognition leads to an increase in documentation speed and amount, and enhances the participant’s mood when compared to self-typing
Summary
The diagnostic and therapeutic procedures of medical professionals lead to a vast number of observations and decisions, which must be documented correctly to ensure the documentation of the medical course, fulfillment of legal aspects, quality reporting, and billing. Electronic health records can interrupt clinical workflows and the treatment procedure, conceivably because of limited availability at bedside. These aspects lead to different beliefs and experiences of health care professionals concerning the general quality of electronic health record systems, clinical day-to-day usability, and user satisfaction [1]. Alternatives to self-typing, such as speech recognition, are currently believed to increase documentation efficiency and quality, as well as satisfaction of health professionals while accomplishing clinical documentation, but few studies in this area have been published to date. Conclusions: We conclude that medical documentation with the assistance of Web-based speech recognition leads to an increase in documentation speed, document length, and participant mood when compared to self-typing. Speech recognition is a meaningful and effective tool for the clinical documentation process
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