New technology: Continuous-speech voice activated dictation

Traditional voice-recognition systems for ED documentation provide structured templates for particular chief complaints. "The doctor can dictate fill in the blanks’ answers to the various questions and blanks in the template," says Jonathan M. Teich, MD, PhD, director of clinical systems research and development for Partners Healthcare System, and an ED physician at Brigham and Women’s Hospital in Boston. An accurate, easy-to-use voice recognition system can improve the speed of documentation, eliminate transcription costs, and make the transcribed record available immediately, says Teich. "A structured-template system could also generate coded data which can be used for billing and for care monitoring (at the cost of flexibility in what you can enter)," he notes.

Over the past two years, breakthroughs in accuracy have led to the availability of continuous-speech, general dictation systems. "These are now being upgraded to be more responsive to medical vocabulary and syntax," reports Teich. "These systems are responsible for most of the excitement about voice recognition, because you can generate a much more flexible note compared to the structured-template systems."

Still, there are potential downsides. "The downsides are that accuracy is not yet as good as we would wish it to be, and that, as a result of this, the net speed of dictation and correction is no more than about 10 to 20 words per minute," Teich notes. "Therefore, this reduces or eliminates the work of a transcriptionist but adds to the physician’s documentation time during a busy emergency department shift."

At New Britain General Hospital, voice activated dictation was implemented in the ED, which sees 50,000 visits annually. "We first tried IBM’s product and have stayed with it through the upgrades: Simply Gold, Via Voice, Via Voice Gold, and Via Voice 98 Executive," says Louis Graff, MD, associate director of the ED at New Britain General Hospital in New Britain, CT.

A medical dictionary was added to each product, says Graff. "We have used the Via Voice Gold for the last seven months for three ED physicians, but we did not move all the other physicians to it because we didn’t think it was good enough. We were using a template to try and make it work best (a paragraph of dictation for history, past history, review of system, etc.)," he explains.

That product was able to transcribe 120 words per minute, so the dictation took three to four minutes, says Graff. "But it took three to four additional minutes to correct the 20 to 30 mistakes per page," he notes.

After upgrading to Via Voice 98, the rest of the physician group switched to the voice activated dictation. "This product only has four to eight mistakes per page of dictation. We feel this is acceptable," says Graff. "We also have a special microphone headset that probably has helped the accuracy as well."

Because the ED has two computers, each working physician can set up the computer with his or her own voice print. "It takes two to four minutes to switch users, so you don’t want to have to waste that time during the shift. Instead, he expains, the physicians keep the computer logged on to their voice print during their shift," says Graff.

Cost savings can be considerable, notes Graff. "Via Voice 98 costs $149 for the software. The computer costs $2000 for a Pentium II, 400 MHz, 128 RAM," he says. "For an emergency department with two physicians working, you need two machines and two copies of Via Voice 98. So the total is $4298 for a 50,000 visits per year ED with 12 physicians, which replaces transcription which costs $10 per chart, at a cost of $500,000 per year.

Instant access to the transcript is another benefit. "It is also immediately available for patient care, whereas transcription often has a four-hour or even 24-hour turnaround time. This is adequate for documentation for reimbursement but not for patient care," Graff says.

Each physician was trained for 30 minutes with one of the experienced physicians, with additional time at home. "Each physician had his own computer at home and was given a copy of Via Voice to load on his own computer so he could practice at home and get experienced," Graff explains.

Four products currently offer medical voice to text continuous-speech recognition, says Todd B. Taylor, MD, FACEP, an ED physician at Good Samaritan Regional Medical Center, Phoenix Children’s Hospital (AZ) and former chair of ACEP’s section on Computers in Emergency Medicine.

"I have been able to test three of them in a relatively controlled way," reports Taylor. "I have found little difference in the underlying speech engine technology. The main difference seems to be how the technology has been implemented (i.e., the front end)," he says. "I believe this is where the main opportunity [is] to make these products usable and practical for the ED."

Computer-generated charting makes sense only when you have more physician time than you have patients, argues Taylor. "It makes sense if the physician can use this down time’ to complete charts," he notes. "Otherwise, time spent completing charts may detract from patient care."

However, this does not account for the added benefits a well-designed, structured charting system may bring to the mix, he notes. "When one considers real-time CQI, use of macro-type’ charting, and immediate availability of the chart, such systems may soon begin to break the cost-of-time conundrum."


Here is a listing of vendors that offer medical voice-to-text continuous speech recognition systems:

• "VoiceXpress for Medicine" by Lernout & Hauspie, 52 Third Avenue, Burlington, MA 01803. Translation Engine: Proprietary. Telephone: (800) 634-8723 ext. 5100.

• "PowerScribe" by the MRC Group, 23240 Chagrin Blvd., Ste. 400, Cleveland, OH 44122. Telephone: (800)342-8283. Fax: (216) 464-4019. World Wide Web: Translation Engine: Dragon’s Naturally Speaking.

• "VoiceDoc for ED" by Alien Robotics, Inc. 6905 Merton Road, Pittsburgh, PA 15202. Telephone: (412) 732-9000. Fax: (412) 732-9002. World Wide Web: Translation Engine: IBM ViaVoice.

• "Vocalex" by Vocalex, Inc. 6718 Loop Road, Centerville, OH 45459. Telephone: (888) VOCALEX. E-mail: Translation Engine: Phillips SpeechMagic.

• Reviews of voice-activated dictation systems appear in the following publications: Windows, August 1998:62-68; PC World, September 1998:74-75; PC World, August 1998:75.