The Role Speech Technology Can Play in Helping to Streamline the EHR Transition

Early adopters – the approximately 15 percent of
doctors who use an electronic health record (EHR) system successfully –
are hitting a major speed bump ahead of their peers: EHRs can slow physicians

Too much emphasis is being placed on EHR
deployment and not enough on utilization.  In the rush to
computerize patient information, per Obama’s five-year goal that all
medical records go digital, it has been assumed that once EHRs are widely
deployed, patient records will automatically be more complete and shareable, administrative
costs will be cut and that universal quality of care will be enhanced.  First,
we have to get doctors to meaningfully use the system…

In a study conducted by Fallon Clinic comparing EHR
technology used as is vs. with speech recognition technology (replacing traditional
transcription and keyboard-only control of the EHR), not only did speech
recognition prove to help doctors capture the patient encounter in more detail;
it helped to save $5,000 per doctor per year in transcription costs and generated
additional reimbursement per encounter.

Additionally, a recent survey of 1,241 doctors who use
speech recognition (Dragon
) to capture dictation and populate the EHR found that:

    83 percent said that it improved the quality of
    their patient notes

  • 81 percent said that it significantly reduced
    transcription spending
  • 69 percent said it made their EHR faster and
    easier to use

According to Dr. Dean Carr, a primary care physician at Group Health Cooperative and Epic EHR user in Seattle, WA,
speech recognition “has really shortened the process of creating
notes.  It shortens my day by 1–1.5 hours because I no longer have
to log in from home to complete chart.”

Studies have shown that in some cases, the adoption of EHRs
themselves does not lead to higher quality care. An April 2008 article in
the New England
Journal of Medicine by Groopman and Hartzband

cited the dangers of over reliance on EHR automation: “This capacity to
manipulate the electronic record makes it far too easy for trainees to avoid
taking their own histories and coming to their own conclusions about what might
be wrong.  Senior physicians also cut and paste from their own notes,
filling each note with the identical medical history, family history, social
history and review of systems.” 

By pairing speech recognition technology
with EHR deployment, doctors are more likely to successfully use the
system.  By dictating their patient notes directly into the EHR vs. typing
their notes, doctors can spend less time on clinical documentation and more
time on patient care.  The return is huge – patient notes are more
detailed and no longer rushed or sloppily-typed.  Moreover, traditional
medical transcription costs can be slashed and insurer reimbursement is often
higher because of more detailed “medical decision-making” – such
as history of present illness, review of systems, assessment and plan.

A solid ROI example of the value of speech
recognition improving the patient documentation process is Beth Israel Deaconess Medical Center in Massachusetts.  They
have achieved cost savings of more than $2 million and decreased turnaround
time (the time from when a patient is seen, to the documentation and
communication of their visit) by 90 percent because of their investment in background
speech recognition technology.  By leveraging speech recognition to support
clinicians’ “free dictation” which can be stored in the EHR, healthcare organizations can speed EHR utilization,
while cutting healthcare costs and improving patient care.

Some physicians have even deployed speech recognition prior
to EHR implementation to generate substantial cash savings which helps pay for
the EHR itself.  “Before we began implementing
the EHR, we leveraged speech recognition to nearly eliminate transcription
costs,” commented Douglas Golding, MD, Medical Director and Chief Medical
Information Officer at Lifetime Health
Medical Group
in Buffalo,
NY and NextGen EHR user.

Golding’s practice covered the full EHR cost with
transcription savings generated by speech recognition.  “As we
implemented the EHR, we found that [speech recognition] facilitated free text
entry where needed.  Now providers create and edit patient reports in one
sitting through free-form dictation.  Report turnaround times have gone
from as much as three weeks to a matter of minutes,” Golding detailed. 
“Best of all, we started saving money almost immediately.  The
payback on our investment took only six weeks.  Most technology payback
periods take two to three years to break even.”

Recent physician surveys, anecdotes and testimonials confirm
that speech technology is a complementary tool to make EHR systems user-friendly.
 So while the EHR transition
will happen
addition to making sure doctors’ efficiency isn’t compromised by
learning a new system, we need to ensure they don’t take shortcuts by
creating cookie-cutter medical records that are void of expression and patient
detail.  Speech let’s the patients’ records maintain their
doctor’s voice (literally) and doesn’t force physicians to be a
slave to the keyboard.

 Keith Belton is VP of Marketing at Nuance Communications.

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duffydooROBERT E CONNORSJeff Kainetcoyotebev M.D. Recent comment authors
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We have an “employment guarantee” so our hospital thankfully cannot “eliminate” transcriptionists with “The Dragon”–instead they must either give them a retirement package they can’t refuse or pay for sometimes costly schooling and retraining and place them elsewhere within the hospital in other positions–so not so “cost effective” from that end.
And from reading the above blog, it appears that doctors have now become medical transcriptionists.


The U.S. military recently embarked upon use of Nuance Dragon Naturally Speaking, Medical, for front end speech recognition with AHTLTA, DoD’s Electronic Health Record. Initial data shows positive results in improving clinician satisfaction with AHLTA use; improving perceived quality of clinical encounter notes; and in some cases, improving productivity ( a few more patients seen), by using macros. Army is also engaged in research of natural language processing, using Language and Computing’s TeSSI NLP engine, to turn text into coded facts. Kaiser is doing similar with Epic to support billing. Robert E. Connors, FACHE, PMP, Executive Health Manager, Henry M.… Read more »

Jeff Kaine
Jeff Kaine

There is no debate that voice recognition is a great tool. I agree with Dr. Flashner, however, that it is nothing more. As a physician using EMR and voice recognition for the past 6 years, it is safe to say that I have considerable experience. I am not EMR and voice recognition is a time saver for me but the quality of my documentation is indeed improved. The time spent in reviewing and correcting documents could easily be spent seeing two more patients/day and the cost issue is a total wash. EMRs using custom designed templates (I use MedTemps EMR)can… Read more »

Tom Leith
Tom Leith

Dr. Rowley writes: > However, the disadvantage is that the notes were > narrative, and thus not in any consistent structure > from one practitioner to another, and no consistent > lexicon was used. Hence, searching text entries was > not really feasible. Slee’s point is that the narrative notes ARE the record and that coding is an abstract of the record. When Natural Language Processing and vocabularies/lexicons are sufficiently developed, then the abstracts can be automatically created and the EMR begins to be useful for all the applications foreseen. I have noted that one can make multiple abstracts of… Read more »


The answer to Margalit’s earlier question is: Yes, this was an informercial. Not clear that THCB should simply be a publicity vehicle for vendors, regardless of how groovy their technology. Matthew take note . . .

bev M.D.
bev M.D.

Actually a well-designed template can improve care by prompting the physician to perform a complete physical examination, for instance. It used to be that taking a history and physical exam followed a well-worn sequence taught to all medical students. Today this sequence is becoming increasingly truncated. With a template, one has to either fill in the blank with the proper data, or admit that it was “ND” (not done). Of course, the downside is that templates discourage reporting of unusual findings that do not appear on the template, if one is too lazy to add them. The bottom line is,… Read more »

Robert Rowley, MD

As a practicing physician who has used EHRs for a number of years, I have used speech-recognition add-ons (like Dragon Systems, for example) to create text in chart note fields. The advantage was savings on transcription costs (we were able to get rid of our transcription service). The disadvantage was the occurrence of correctly-spelled nonsense that needed proofreading before saving. This was certainly an advantage over hand-written (read that: hand-scribbled) notes, and had faster turnaround than with a transcriptionist. However, the disadvantage is that the notes were narrative, and thus not in any consistent structure from one practitioner to another,… Read more »

Gary M. Flashner, MS, MD

It is unfortunate that Mr. Belton has the serious misconception that speech recognition in and of itself will somehow magically generate more complete charts, higher reimbursement, and yield more time for patients. This notion is just as misguided as the notion that EMRs will somehow immediately yield much lower drug/medical error rates, allow for seamless information sharing among many clinicians/hospitals, and lower the overall cost of healthcare. Speech recognition is a tool—period. A stethoscope is also a tool. Both are very cheap and very powerful. Both require training and practice in order to realize their benefits to the clinician, and… Read more »

J Bean
J Bean

Tom Leith summed it up pretty well. There is technology and then there is appropriate technology. Unfortunately, the current crop of EHRs are focused on preserving a bunch of unnecessary billing/malpractice defense boilerplate crap rather than collecting and generating usable information. As a primary care physician, I never, ever look at old physical exam data for anything other than blood pressure and weight. I record the data so that I can bill insurance and so that I have proof that I checked blah, blah, blah, if I ever get sued. The EMR that I use now is a badly designed… Read more »

Joe Buckle

Healthcare professionals have alternative solutions available in speech recognition. Windows Vista now has speech recognition built into the OS and third party medical topics can be added from Trigram Technology. The topics allow physicians and healthcare users to dictate into any program on the PC. Also, since the medical topics seamlessly integrate into Windows Vista developers can take advantage of existing Microsoft code to link their program with speech recognition. In fact, many programs written in Microsoft Visual Studio require very little additional development since the speech engine is embedded into the Vista OS and can read menus and make… Read more »

Tom Leith
Tom Leith

> I think physicians are educated enough > to make their own decisions regarding > their own documentation. Left on their own, they’d do a lot less of it: a great deal of documentation is about billing third parties and defending lawsuits — two activities docs aren’t all that thrilled about doing. EHRs aren’t meaningfully used because they don’t add any particular value from the doctor’s point of view. Even if EHRs were no more onerous to use than dictation for transcription (do not underestimate the difficulty of doing this properly), this basic fact doesn’t change. But until EHRs are… Read more »


I happen to be an IT person with 26 years in the business, and I think EHR is a byproduct, not the driving force.
Rethinking how we render medical care is at the core. The processes are key, and the people who go along with it essential. Technology is the artifact we have AFTER we figure out the rest.
Kindly refrain from generalizing. Not all IT people are propeller heads. 🙂

Margalit Gur-Arie

Is this an infomercial?
Speech recognition is important and so is digital inking and scanning and macros and templates and any other methodology for documenting a visit.
I just don’t think it’s the IT folks job to “ensure they don’t take shortcuts by creating cookie-cutter medical records that are void of expression and patient detail” – they, being the doctors.
I think physicians are educated enough to make their own decisions regarding their own documentation. Let’s concentrate on providing them with usable tools to do their job and not presume that IT knows the “right way” to perform that job.

Healthcare Guru

Only IT people think that EHR is save all solution. In the current form, it is at the most a warehouse with some positive. For it to be usefull as IT folks are saying, there need to be new strategies and policies. We need new EHR system. For example, one of the article I wrote on my blog, I proposed it more patient controlled, and so on. speech recogninition is easrier for physicians but then it is also just a repository…it does not add any intelligence of use. Unless of course, the recordings are being passed to LCCs for transcription.… Read more »