Taking Your Clinical Documentation to the Next Level With Voice Recognition

Does it sometimes feel like the medical world is the last to adapt to new technologies, no matter how helpful they might be? A revealing 2017 article in the Pharmacy and Therapeutics journal cited the astonishing fact that an estimated 63% of physicians were still using the fax machine as a primary means of communication as recently as 2012!

Despite all the advances in technology and digital communications, many medical practitioners still rely on what they consider to be a tried and true approach. While they might not use an adding machine for their billing and insurance claims, some are still dictating their notes into a recording device for later transcription. Many have used this approach for years and say they just simply feel more comfortable with it. The thought of learning a new technology can be alarming, but sometimes the results can be worth the effort.

Since the 2009 adaptation of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the move toward electronic health records (EHRs), increased patient communication, and the requirement for interoperability among health care providers is forcing the issue with many practices. In order to be compliant with this legislation, providers must be able to demonstrate “meaningful use” of an EHR system to improve the quality, safety, and efficiency of patient care.

As the number of providers that utilize EHRs rises, it would seem that the use of voice recognition would also rise accordingly, but many still pine for the “good old days” of dictation and typing. Surprisingly enough, though, a study cited in the Journal of the American Medical Informatics Association found that continuing to use dictation as the primary means of documentation instead of adapting to EMR and voice recognition may actually result in an inferior level of patient care quality.

The idea of involving additional players in a transcription scenario can also increase the possibility of medical errors. If the transcriber is distracted or does not hear the recording properly, an instant error appears in the patient’s medical record. This may be caught in the review process, but unnecessary steps might have been taken in the interlude. In a worst-case scenario, some practices rely on outsourced medical transcription services in an effort to reduce costs, but this can lead to even more problems when transcribers who do not use English as their primary language try to decipher complicated medical terminology. Other problems associated with the dictation and transcription system include:

• There can be problems understanding and transcribing accents, idioms, and use of medical terminology.
• Different transcribers might interpret the same information in different ways.
• A poor audio recording quality can lead to poor results.
• The time lag between the patient visit and the dictation may lead the provider to forget certain details of the patient interaction.
• Additional time is required for transcription, which may result in a lapse in patient care if an incident should occur during the transcription period.
• The need for the provider to review transcribed notes results in an additional drain on time.
• Administrative costs can be high for medical transcription time.

The use of voice recognition software in conjunction with an in-house EHR system can deliver many benefits related to clinical documentation. The practice can save time, develop more detailed documentation, comply more fully with government regulations, improve overall care, and even find additional time for patient visits.