Transcript Presentation Title Placeholder

Speech Recognition & The Persistence of Narrative
Documentation in the EHR Environment
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Don Fallati
VP-Senior Advisor
A Union of Speech Recognition
Industry Leaders
A Union of Speech Recognition Industry Leaders
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The Clinical Information Challenge:
How Do We Automate Narrative?
CPR
CPOE
CLINICAL
AUTOMATION
Devices/
Dept Systems
Patient
Documentation
Clinical Information
Benefits:
• Cost Savings/Efficiency
• Quality/Patient Safety
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Voice: Fastest Information Entry Modality
Average text-entry time using various input mechanisms
(expert users)
Input Device
Average Time
Mobile phone keypad
1:57
Mobile phone keypad
1:15
(T9 predictive text)
RIM Blackberry
0:57
(QWERTY keyboard)
RIM Blackberry 7100
0:59
(predictive text)
Desktop PC
Text segment used:
“Speech Recognition’s record
breaking accuracy
improvements make using
speech recognition easier than
ever before.”
0:22
(QWERTY keyboard)
Voice
0:12
(Mobile dictation)
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Narrative Paradigm
• Medical reporting is capturing stories
• Narrative will persist for a long time and there will be a lot
of it
• EMR documentation paradigm flawed
• Need to change the game
• Need Narrative-based structure
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Persistence of Narrative
• Narrative will stay because:
–
–
–
–
Natural form of communication
Comfortable to create
Voice friendly
Provides nuance, detail,
context
– Supports comprehensive
documentation
– Not just habit
• Narrative remains.
• Transcription, as we know it
today, may not.
Diagnoses are acut e inf erior w all M I and t ype II diabet es. Perf ormed cardiac
cat het erizat ion and a coronary angioplast y of t he right coronary art ery.
Upon discharge pat ient prescribed Lopressor 25 mg. p.o. b.i.d. Also ent ericcoat ed aspirin 325 mg. p.o. per day and Glyburide 2.5 mg. p.o. q AM . Dr.
[RNAM E] consult ed on t he case.
HPI t his is t he f irst [RCLINIC] admission f or a 67 year old w hit e male w ho w as
t ransf erred f rom [RCLINIC] f or cardiac cat het erizat ion and possible
int ervent ion. He had been admit t ed t o t hat f acilit y on [RDATE] w it h a one
t o t w o w eek hist ory of crescendo angina, described as chest pain and
pressure w it h radiat ion t o his arms w hich w as occurring w it h act ivit y and
w as becoming more f requent , and w it h easier onset of act ion. He had no
previous cardiac hist ory, myocardial inf arct ion or congest ive heart f ailure. He
denied any dyspnea on exert ion, PND, ort hopnea, pedal edema, palpit at ions
or syncope. Risk f act ors f or coronary disease include a hist ory of non insulin
dependent diabet es, hypert ension, f amily hist ory. Cholest erol st at us w as
unknow n. He had no hist ory of t obacco abuse. Did not drink alcohol.
Pat ient had a bilat eral herniorrhaphy and is allergic t o penicillin. Pat ient
w as already t aking Glyburide and Lisinopril and aspirin. Exam inf o pat ient is
a w ell developed man, no dist ress. St able vit al signs. No increased JVD.
Lungs clear. Normal heart sounds w it hout rub, murmur or gallop. Abdominal
area sof t w it hout organomegaly, mass t enderness or bruit s. GU def erred.
No cyanosis, clubbing or edema. Good peripheral pulses. Neurological
int act . EKG revealed a QS pat t ern in leads 2, 3 and F w it hout ot her ST
segment abnormalit ies. This gent leman had undergone a st ress t est at
[RCLINIC] prior t o his t ransf er w hich w as markedly abnormal w it h ST
segment elevat ion in t he inf erior leads, and f or t his reason it w as f elt t hat he
w ould require cat het erizat ion. Subsequent laborat ory st udies revealed
slight ly elevat ed t roponins, borderline elevat ed CK's and elevat ed M V's.
The pat ient w as t ransf erred t o t he CCU and w as cont inued on Heparin and
Tridil. The f ollow ing morning w as t aken t o cat het erizat ion laborat ory and
underw ent successf ul balloon angioplast y of his post erior descending art ery.
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Three Solutions taking aim at transcription
Outsource
Speech
Transcription
EMR
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Dictaphone Documentation Automation
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Speech Recognition Editing Styles
Speech Recognition
with NLP
Transcription-assisted
Provider-driven
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Integrating Speech Recognition Into Workflow Platforms
Workflow Platform
Server Based
Speech Recognition
EHR
Desktop Based
Speech Recognition
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State of Speech Recognition Today
• Over 1200 systems sold
• Covering broad range of medical specialties
• Inpatient and outpatient usage
• Large and small institutions
• Being applied to high percentage of daily volume
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Gartner Healthcare Technology Hype Cycle
SR Transcription
SR Once and Done
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Productivity Gains - Radiology
• 900 systems sold
• Elimination of
hundreds of
thousands of $ annual
transcription cost
• 24-48 hour
turnaround times
slashed to a few
minutes
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Productivity Gains
Transcription-Assisted SR
Name
Overall
Productivity
Top MT
Number of
Dictators
Monthly SR
Volume
SR % of Total
Volume
54%
217%
105
17,600
35%
30%
156%
101
8,000
75%
Brooks Memorial
43%
85%
32
392
62%
Reading Hospital
29%
388%
66
1,695
27%
59%
361%
62
2,592
87%
Rush Foundation
Hospital
40%
41%
18
343
15%
AthletiCo
41%
99%
300
8,000
78%
Regions
29%
68%
98
2,000
14%
43%
141%
350
12,900
22%
Affinity Health
Systems
Advanced Healthcare
Outagamie Health
Dean Medical Center
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Self-Edit Non-Radiology Case Study
Self-Edit
Camino
Healthcare
Users
Reports
180
7,665
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The Physician Adoption Challenge – User Interface
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The Physician Adoption Challenge – User Interface
The Mobile Vision Any Device, on Any Network
PDAs
Telephones
Mobile
Phones
Computers
Laptops
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The Physician Adoption Challenge – Time
• Breakthrough Dictaphone technology creates
new time savings:
– Reuse of previously dictated material
• Multiplier effect with other speech recognition
features
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Natural Language Processing
What does it do?
Natural Language
Processing
Dictated Medical Report
Sectional
Tagging
Clinical Data
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“Jump Start” Technology
NAME: John Doe
LC#: 0992612
ADMISSION DATE: 09/14/02
DISCHARGE DATE: / /
ATTENDING PHYSICIAN: A. Physician, MD
CHIEF COMPLAINT: Right ureteral calculus.>
ASSOCIATED DIAGNOSES:
1. History of nephrolithiasis. The patient is status post multiple lithotripsies in the past.
2. The patient is status post nephrolithotomy in 1978.
3. The patient with hypertension.
4. The patient with gout.
HISTORY OF PRESENT ILLNESS/REASON FOR ADMISSION: The patient is a pleasant 75-year-old
gentleman with a prior history of urolithiasis, status post left nephrolithotomy in 1978, and
multiple lithotripsies, and now presents with 12-hours of right flank pain. He denies any
associated diaphoresis, nausea, vomiting, fever, chills, chest pain, shortness of breath, change
in bowel habits, or change in his urinary habits. He denies any recent passage of calculus,
fragments in his urine, and denies hematuria, dysuria, frequency, or urgency. His flank pain is
similar to his prior renal colic and does not radiate. It is approximately 7 out of 10 in severity
and comes and goes in waves. He has otherwise been in his usual state of health. He recently
underwent an exercise tolerance test in July of 2002 which was within normal limits. This was
initiated on review of a new right bundle-branch block on EKG.
PAST MEDICAL HISTORY:
1. As above.
2. Hypertension.
3. Gout.
MEDICATIONS: Plendil 5 mg p.o. q.d.; Diovan 80 mg p.o. q.d.; indomethacin; and allopurinol p.r.n.
ALLERGIES: PENICILLIN AND AMPICILLIN.
FAMILY HISTORY:
SOCIAL HISTORY: The patient denies any tobacco or ethanol use.
REVIEW OF SYSTEMS:
PHYSICAL EXAMINATION: On exam he is afebrile with a temperature of 98.1, pulse is 83, blood
pressure 170/88. He is breathing at a rate of 16. He is in no apparent distress. He has no
diaphoresis. HEENT: He is anicteric. NECK: He has no carotid bruits. CHEST: His lungs are clear.
HEART: Regular. ABDOMEN: Soft, nondistended. He has mild right lateral abdominal pain;
however, no guarding and no peritoneal signs. He has normal male genitalia with descended
testes bilaterally. There are no inguinal hernias. RECTAL: Exam notes a 3+ smooth prostate.
EXTREMITIES: Within normal limits. OTHER:
LAB DATA:
EKG: CT SCAN: Noted an 8-mm right proximal ureteral calculus with hydroureter and hydronephrosis
and mild perinephric stranding. The left side also had a 5-mm renal calculus and a mild pull
calix. There was no hydronephrosis or hydroureter on the left. DIAGNOSTIC: Significant for a
creatinine of 2.1. His last prior creatinine was 1.3, checked in July. His white blood cell count
was elevated to 17.8, and his hematocrit was 44.3. Urinalysis revealed a pH of 5.0 with red
blood cells and white blood cells as well uric acid crystal within.
ASSESSMENT: The patient is a 75-year-old gentleman with a history of urolithiasis and hyperuricemia
with an obstructing right ureteral calculus, elevated white count, intractable pain, and rising
creatinine.
GOALS/TREATMENT PLAN: The plan for the patient is to remain n.p.o., to have alkalinization of his
urine with sodium bicarbonate and D-5-W and to go to operating room for ureteral stenting. He
will be treated preoperatively and postoperatively with IV antibiotics and will be admitted to
the hospital.
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“Jump Start” Technology
Discharge Report Automation
NAME: John Doe
LC#: 111111
ADMISSION DATE: 09/14/02
DISCHARGE DATE: 09/16/02
ATTENDING PHYSICIAN: A. Physician, MD
PRINCIPAL DIAGNOSIS: Right ureteral calculus.
PRINCIPAL PROCEDURES:
1. Cystoscopy.
2. Placement of right double J stent on 09/14/02.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant 75-year-old gentleman with a prior history of
ureterolithiasis, status post left nephrolithotomy in 1978 and multiple lithotripsies, who now
presents with a 12 hour history of right flank pain. He denies any associated diagnoses,
nausea, vomiting, fever, chills, or chest pain. He reports no change in bowel habits or change in
his urinary habits. He denies any recent passage of a stone and denies hematuria, dysuria,
frequency, or urgency. He reports that his flank pain is similar to his prior episodes of renal
colic. He states that his pain is approximately 7 out of 10 in severity and comes and goes in
waves. He has otherwise been in his usual state of health.
PAST MEDICAL HISTORY:
1. As above.
2. Hypertension.
3. Gout.
MEDICATIONS ON ADMISSION: Plendil 5 mg p.o. q.d.; Diovan 80 mg p.o. q.d.; Indomethacin p.r.n.;
allopurinol 0.625 mg p.o. q.d. p.r.n.
ALLERGIES: THE PATIENT REPORTS ADVERSE REACTION TO PENICILLIN AND AMPICILLIN.
SOCIAL HISTORY: The patient denies any tobacco or ethanol use.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile and his vital signs were stable. In
general, he was alert, oriented, in no apparent distress. His head and neck exam was
unremarkable. His lungs were clear to auscultation bilaterally and his heart had a regular rate.
His abdomen was soft, nontender, nondistended. He had no evidence of peritoneal signs. He
had normal male genitalia with descended testicles bilaterally. His extremities were warm and
nontender. Rectal exam was significant for a 3+, smooth prostate.
HOSPITAL COURSE: The patient was admitted and taken to the operating room, where he underwent a
cystoscopy and double J stent placement. Postoperatively he was admitted to the floor. On
postoperative day 1, he was continuing to have some mild discomfort in his right flank. He was
otherwise tolerating a regular diet and ambulating without difficulty. Of note, he did have an
elevated creatinine of 2.1 on admission. His creatinine had fallen to 1.8. On postoperative day
2, his pain had resolved and he was tolerating a regular diet. He was ambulating without
difficulty. His pain was well controlled with p.o. pain medication. He was started on Polycitra in
order to alkalinize his urine. He was discharged home with followup.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: The patient will follow up with Dr. Michael Malone in the office as an
outpatient with a stone protocol CAT scan of his abdomen and pelvis. In addition, he will have a
blood urea nitrogen and creatinine level drawn at the same time, prior to his visit.
DISCHARGE MEDICATIONS: Plendil 5 mg p.o. q.d.; Diovan 80 mg p.o. q.d.; Indomethacin p.r.n.;
allopurinol 0.625 mg p.o. q.d. p.r.n.; Polycitra 1 packet p.o. t.i.d. with meals; Bactrim DS 1 tab
p.o. b.i.d. x 3 days; Tylenol No. 3 1-2 tabs p.o. q.4-6 h. p.r.n.; Colace 100 mg p.o. b.i.d. p.r.n.
from
HIM Database
from
H&P Report
from
Normals
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Report Completion by Shortcuts and Reuse
21%
31%
>70%
>50%
<50%
48%
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The Physician Adoption Challenge – Speech &
the EMR
Low
High
Dictation
“Natural
Language”
Patient
Record
Physician
Usability
Install
Cost &
Complexity
EMR
with
structured
data
Low
Data Quality & Re-usability
High
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Speech Can Address the Various Hospital/Clinic
Scenarios
1. No EMR Interest or Intent
2. Actively Considering EMR
3. Implementing EMR –Concerned with Adoption
4. Deployed and Using
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Speech Enable the EMR
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Migrating the Physician
Traditional
dictation
Background MT
Speech Rec
Phys self-edit
Speech Rec
SR & NLP structured
report / data creation
The “Natural
Language”
Patient Record
Natural
Language
Bridge to
Clinical
Automation
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