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

• Published in: Journal of biomedical informatics Vol. 77; pp. 91 - 96
• Main Authors: Payne, Thomas H., Alonso, W. David, Markiel, J. Andrew, Lybarger, Kevin, White, Andrew A.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.01.2018
• Subjects: Automatic speech recognition; Data Accuracy; Documentation - methods; Documentation - trends; Electronic health records; Electronic Health Records - organization & administration; Electronic Health Records - trends; Hospital care; Humans; Medical Records; Mobile Applications - standards; Physician documentation; Physicians; Practice Patterns, Physicians; Speech Recognition Software; User-Computer Interface; Workflow; Workflow; Physician documentation; Electronic health records; Hospital care; Automatic speech recognition
• ISSN: 1532-0464; 1532-0480
• DOI: 10.1016/j.jbi.2017.12.004

[Display omitted] •Creating notes represents one of the most problematic aspects of EHRs for physician users.•We describe a system to use voice to create progress notes in a way that fits rounding workflow.•We used commercial automatic speech recognition, and vendor tools to integrate with the EHR.•This is alternative method to create progress notes is for physicians who prefer voice to typing. 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.