Using voice to create hospital progress notes: Description of a mobile application and supporting system integrated with a commercial electronic health record

We describe the development and design of a smartphone app-based system to create inpatient progress notes using voice, commercial automatic speech recognition software, with text processing to recognize spoken voice commands and format the note, and integration with a commercial EHR. This new system fits hospital rounding workflow and was used to support a randomized clinical trial testing whether use of voice to create notes improves timeliness of note availability, note quality, and physician satisfaction with the note creation process. The system was used to create 709 notes which were placed in the corresponding patient's EHR record. The median time from pressing the Send button to appearance of the formatted note in the Inbox was 8.8 min. It was generally very reliable, accepted by physician users, and secure. This approach provides an alternative to use of keyboard and templates to create progress notes and may appeal to physicians who prefer voice to typing.

[1]  Barbara Sheehan,et al.  Natural Language Processing–Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A Comparative Usability Study , 2016, JMIR medical informatics.

[2]  D. Blumenthal.  Launching HITECH. , 2010, The New England journal of medicine.

[3]  Mark W Friedberg,et al.  Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. , 2013, Rand health quarterly.

[4]  John Strauss,et al.  Speech recognition software and electronic psychiatric progress notes: physicians' ratings and preferences , 2010, BMC Medical Informatics Decis. Mak..

[5]  James A Levine,et al.  Internal medicine residents' computer use in the inpatient setting. , 2012, Journal of graduate medical education.

[6]  Woojin Kim,et al.  Radiology reporting: a closed-loop cycle from order entry to results communication. , 2014, Journal of the American College of Radiology : JACR.

[7]  M. Christino,et al.  Paperwork versus patient care: a nationwide survey of residents' perceptions of clinical documentation requirements and patient care. , 2013, Journal of graduate medical education.

[8]  A. Wu,et al.  In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time? , 2013, Journal of General Internal Medicine.

[9]  Kenric W. Hammond,et al.  Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication , 2003, AMIA.

[10]  Thomas H. Payne,et al.  Transition from Paper to Electronic Inpatient Physician Notes Case Description , 2022 .

[11]  R. Wassmuth,et al.  Analysis of Documentation Speed Using Web-Based Medical Speech Recognition Technology: Randomized Controlled Trial , 2015, Journal of medical Internet research.

[12]  Hua Xu,et al.  Data from clinical notes: a perspective on the tension between structure and flexible documentation , 2011, J. Am. Medical Informatics Assoc..

[13]  E. Siegler,et al.  Copy and paste: a remediable hazard of electronic health records. , 2009, The American journal of medicine.

[14]  Christine A. Sinsky,et al.  Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties , 2016, Annals of Internal Medicine.

[15]  Joel M Yarmush,et al.  Typing skills of physicians in training. , 2014, Journal of graduate medical education.

[16]  John B. Shoven,et al.  I , Edinburgh Medical and Surgical Journal.

[17]  Kevin J O'Leary,et al.  Where did the day go?--a time-motion study of hospitalists. , 2010, Journal of hospital medicine.

[18]  Thomas H. Payne,et al.  Improving Electronic Inpatient Progress Notes Using Voice: Results from the VGEENS Project , 2017, AMIA.

[19]  Christine A. Sinsky,et al.  Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. , 2016, Mayo Clinic proceedings.