When the U.S. Department of Defense set a 2011 deadline to develop a fully operational, globally interoperable EHR for military personnel and their families, many physicians balked at the technology. Point-and-click software meant less time with patients and more hours logged at a computer screen. Now, speech recognition technology (SRT) is bringing documentation back into the exam room and improving the way doctors serve our finest.

A Grassroots Operation

For the past couple of years, the military had been expanding its use of SRT. What once began as an individual preference has now become an institutionalized practice through the military's partnership with Nuance Communications, a provider of speech recognition software. Currently, more than 6,000 military clinicians use Dragon Medical to dictate information directly into a patient's record.

But it wasn't always popular. "There certainly was a lot more low-level grassroots interest before there was high interest in [speech recognition]," said Valerie Matthews, principal federal sales engineer for Nuance.

An early backer of SRT, Robert Marshall, MD, MPH, MISM, director of clinical informatics, Bureau of Medicine and Surgery, Department of the Navy, first encountered speech recognition almost 10 years ago while treating troops in Korea and Japan. Dr. Marshall used a small PDA-like device equipped with SRT to translate medical advice to Japanese, Korean and Thai troops who needed treatment. When Dr. Marshall returned home from his most recent overseas tour, he began advocating for everyday use of SRT.

Proponents of SRT seized an opportunity when the military implemented its EHR system, the Armed Forces Health Longitudinal Technology Application (AHLTA). The electronic system was intended to improve efficiency, but instead physicians felt they were becoming "data entry operators," Matthews said. According to doctors, more time was logged tapping keystrokes in the office than meeting face-to-face with patients.

Physicians were also unhappy with the notes that point-and-click EHR software produced. Robert Walker, MD, a physician at the European Regional Medical Command (ERMC) in Germany, said the non-narrative notes left much to be desired. "The type of note produced in a point-and-click system had no depth, quality or tone," Dr. Walker said.

Such elements are essential when documenting a patient's medical history. "By not having them," Dr. Walker explained, "we were producing a note that was not only difficult to read, but it was taking us longer to put that information into the computer."

Dr. Walker was similarly discouraged by how the computer disrupted the usual physician-patient interaction. Data entry on a desktop computer shifted valuable focus away from the patient. "We were looking more at the computer screen than at the patient; typing instead of talking; reading rather than listening," he said.

The constant typing also kept Dr. Walker with his back to the patient, which he said was wrong. "It was as if the computer became the third person in the room and was getting more attention than the patient," he recalled. "There had to be a better way."

Dr. Walker would often wait to complete his documentation after the patient left, a situation that wasn't ideal; the delay not only made his day longer, but also forced Dr. Walker to remember specific patient details at a later time. "That's not good from a patient safety standpoint, nor does it make much sense from a time management perspective," Dr. Walker said. "It really goes against everything we've been brought up with."

Dr. Walker had tried SRT in the past, but free-text-a more narrative note compared to standard templates-was initially not encouraged for use in AHLTA. About a year ago, however, the door opened for use of free-text, and Dr. Walker began advocating for SRT.

Help on the Homefront

In its most basic form, SRT "replaces your keyboard," Matthews said. Instead of clicking through charts or selecting items from a drop down menu, physicians speak into a microphone and the software translates their words into text on the screen. Translation is instantaneous, so documentation is often faster than typing or clicking through notes. Improved productivity means that doctors are free to see more patients or even go home to their families "at a reasonable hour," Matthews said.

SRT transcribes exactly what the doctor dictates, so the endproduct is a narrative text instead of choppy text Dr. Walker said "resembles a ransom note." The readable text makes it easier to follow a doctor's train of thought and rationale for formulating a diagnosis and treatment plan, Dr. Walker said. That becomes particularly helpful in the military when both patients and providers move frequently.

Dr. Marshall said while the readable text is convenient, it cannot be mined for data quality or measures. However, Dragon software can be used in combination with structured text, which follows a template and enables data mining for research or auditing purposes. With both structured and unstructured texts, medical practices can get the best of both worlds, Dr. Marshall said.

Another rising trend among military physicians is the use of wireless tablets, which are portable computers about the size of a thin textbook. When combined with SRT, they enable doctors to document in a more patient-centric way. Dr. Walker said the mobile device-as opposed to a stationary desktop-lets him walk from room to room and document in real time while standing face-to-face with his patients. But the real benefit of documenting in the exam room is improved patient care. Dictating directly into the EHR allows the patient to hear exactly what is being documented, Dr. Walker noted. So if a doctor dictates that a patient's right ankle was injured, but the injury was actually on the left ankle, the patient is there to correct the error.

"If I were to wait and document after the patient leaves, the error would not be caught," Dr. Walker said. "That can lead to patient errors and is a safety issue."

Dr. Walker also found that SRT makes the record "transparent" to his patients; they take his instructions more seriously when they see his words directly transcribed into their charts. "It reinforces things," he said.

Dr. Marshall also prefers to dictate in the exam room. "When I'm speaking in front of the patient, I get immediate feedback," he said.

For patients who can't make it to the office or who simply don't want to sit in the waiting room, Dr. Marshall uses SRT with another emerging trend: patient-provider messaging. The doctor communicates with a patient via secure e-mail, so the patient can voice minor complaints and get answers without stopping by the office.

"It's very good for follow-up too," Dr. Marshall said. "With patients for whom I have lab results or an ongoing work-up, I can share results and we can go over things."

Dr. Marshall "writes" his e-mails by dictating through the SRT program. He said the e-mails give him better, more complete notes than he would get from a telephone consultation.

Customized Care

When SRT software encounters a word that it does not recognize, such as a local term or unique name, doctors must manually add the word to the program's vocabulary bank. The partnership between AHLTA and Nuance, however, took this feature a step further and now offers a complete list of military-related vocabulary that doctors can download to bring customized care to uniformed men and women. The list includes the names of every military base in the world, all military hospitals and clinics and all military ranks.

The technology is also adapting to changes within the military. The most recent version of Dragon Medical has been programmed to recognize Spanish-accented speech. "There are a lot of doctors in the military for whom Spanish is their first language, so this will make the software much more usable for that population," Matthews said.

While doctors are working with SRT at different skill levels, they hail shortcuts-called "macros"-as the key to more efficient documentation. Macros allow doctors to place large amounts of text into a patient's record with a simple voice command. The shortcut is particularly helpful for making routine medical notes, which frequently require the same or repeated information. For example, about 85 percent of documentation for routine low back pain is the same, Dr. Walker said. By using a macro, a doctor can simply say, "insert exam low back pain" and the whole exam will be instantaneously placed in the note. As for the 15 percent that is unique to the patient, the doctor can make any necessary changes to the record by selecting those elements and dictating over them, Dr. Walker said.

Near and Far

Macros assist physicians on an individual basis, but the shortcuts have even greater potential when shared with the larger medical community. Dr. Walker is currently working to create macros that can be accessed by any physician in his region. The Army has clinics throughout Europe, so posting macros to a Web site where doctors could download them would not only reduce documentation time, but also rein in the distance between clinics. It's not a "cookbook" approach to medicine, Dr. Walker explained, because doctors can modify the macro according to each patient's case.

Dr. Walker gave the example of creating a macro on community- acquired bronchitis: a doctor would write out the macro and then send it to a pulmonologist who would make annotations. After the pulmonologist, the macro would go to a coder, who would provide guidance on the proper documentation to receive maximum reimbursement. Finally, the macro would be posted on a Web site, where a doctor in the ERMC could download it. The doctor can then use the assigned voice command to fill the patient's chart, make appropriate changes and have the added convenience of the document being pre-approved by the pulmonologist and already coded for reimbursement.

Another example would be a condition like Methicillin-resistant staphylococcus aureus (MRSA), a highly contagious infection that is difficult to treat. A MRSA macro approved by the infectious disease consultant and posted on the ERMC Web site would provide a doctor stationed in Italy up-to-date information on how to treat an infected patient without having to call the specialist.

While Dr. Walker is using macros to reach Europe from his office, other physicians are bringing SRT onto the battlefield, treating troops in combat zones in Iraq.

Speech recognition has proven a valuable addition to the armed forces' combat-ready documentation system, MC4, which allows clinicians to input and store medical data when an Internet connection is unavailable. "When communication is available, critical medical data is sent to a central repository where information can be aggregated and become part of service members' lifelong medical records," said Lieutenant Colonel William Geesey, commander and product manager of MC4.

LTC Geesey said doctors at the Balad Air Force Theater Hospital in Iraq pioneered the use of SRT in combat areas. "They took an important task-documenting patient care-and further streamlined it by using speech recognition software," Geesey explained.

Basic Training

While physicians laud the benefits of SRT, they admit it's not an easy skill to master. Dragon software has nearly 100 percent accuracy right out of the box, but users need thorough training to ensure the technology reaches its full potential.

Dr. Walker divided the learning curve into three stages. The "wow" phase is when the physician first sees the technology in action and is eager to learn its features. Then comes the frustration phase, when the user faces minor setbacks and may argue that SRT is too technical. Finally, the user clicks with the software, ushering in the "I get it" phase. Once physicians reach the "I get it" phase, they won't practice without it, Dr. Walker asserted. The microphone becomes as common a tool as a stethoscope.

The frustration phase can be an uphill battle, so it's up to SRT advocates to encourage the fight. "It's like a speed bump; some hit it and don't seem to get over it," Dr. Walker said. "It's our jobs as their advocates to help them over that bump."

Many physicians are comfortable with the way they practice-whether using point-and-click software or still scratching out handwritten notes-so the shift to new technology like speech recognition requires some encouragement and guidance. "Eight to 10 percent of folks will pick [SRT] up and adopt it on their own," he said, "but the other 90 percent of those licenses will sit there and collect dust."

Dr. Walker suggests a consistent regimen including an initial one-on-one training session for a couple hours, then regular follow ups to address any difficulties the physician is having.

Part of training also includes managing expectations. "Don't promise more than you can deliver," Dr. Walker said.

While Dragon offers a training course, Dr. Marshall has found that peer-to-peer training is most effective. "We've learned a lot of tips and tricks," he said, "and that's what it requires-sharing those tips and tricks with people."

In addition to proper training, SRT works best when paired with a high-quality microphone and good processing system that can support the data load, Dr. Marshall noted.

The Battle Plan

With the home base and international arenas abuzz with talk of EHRs and health information networks, the military's use of SRT is likely to expand in the coming years. Both the Army and Navy recently purchased an additional 10,000 and 2,200 licenses from Nuance, respectively. Matthews said the growth is evidence of a more "systematic integration" of SRT, as opposed to implementing the technology on a facility-by-facility basis.

Dr. Marshall sees potential for SRT use in the Wounded Warrior program, which provides injured military personnel with superior medical care even after discharge. The program has not implemented SRT yet, but Dr. Marshall said case managers would be ideal candidates for it, as they commonly use text-based notes; the Wounded Warrior program often handles patients with "amputations, traumatic brain injury, mental health issues-and a lot of those are very similar," Dr. Marshall explained. "You could easily shortcut those with Dragon text macros."

With a number of opportunities for SRT ahead, the future holds promise. For many years, the technology was not up to par, Dr. Walker said, but improvements in accuracy and the coupling of SRT with wireless tablets have brought speech recognition into the spotlight. "The moment has arrived," Dr. Walker said. "We're about to see a paradigm shift in the way we document health care."

Cheryl McEvoy is an editorial assistant with ADVANCE.

Expanding the Home Base

The military's partnership with Nuance Communications Inc. is helping spread speech recognition technology (SRT) worldwide. From a naval base on the East Coast to the frontlines of Iraq, physicians are using Dragon software from Nuance to ensure military personnel have complete and accurate records wherever they deploy.

Now, Nuance is expanding its domain to European civilians. This past October, the Massachusetts-based company acquired Philips Speech Recognition System (PSRS) from Royal Philips Electronics Inc. for $96.1 million. Headquartered in Vienna, Austria, PSRS provides an avenue through which Nuance hopes to strengthen its presence in the overseas health care sector.

"It's very important to have a strong international presence," said Bob Wise, president of Nuance's Dictaphone health care division. Wise said apart from military bases, Nuance's business has been largely concentrated in North America. The purchase of PSRS, however, brings an experienced European team and expanded client base to the table.

The acquisition followed a year of evaluation and "on again/off again" negotiations with Philips, according to Wise. Ultimately, Nuance was eager to move into the European market, and PSRS had a business model and portfolio that Nuance "could not replicate," Wise said.

Marcel Wassink, CEO of PSRS and vice president of Nuance EMEA said Nuance was attracted to the strong position PSRS held overseas, particularly the company's pre-existing customers, partnerships and support for foreign languages. Philip's speech recognition platform, SpeechMagic, will continue to function under Nuance's ownership, and Wassink said he expects the platform to grow.

Currently, Nuance will focus on the non-military market in Europe, but Wise didn't shrug off the possibility of bringing SRT to other nation's armed forces in the future. In fact, Wassink said they are looking to bring speech recognition to Spain's ministry of defense. "We're rolling out SpeechMagic across that whole global defense organization," he said.

-Cheryl McEvoy