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

被引：24

作者：

Payne, Thomas H. ^{[1
,4
,5
]}

Alonso, W. David ^{[2
]}

Markiel, J. Andrew ^{[4
]}

Lybarger, Kevin ^{[3
,6
]}

White, Andrew A. ^{[1
,5
]}

机构：

[1] Univ Washington, Dept Med, RR-512,Hlth Sci Bldg,Box 356429, Seattle, WA 98195 USA

[2] Univ Washington, Dept Anesthesiol & Pain Med, Box 356540,1959 NE Pacific St,BB-1469, Seattle, WA 98195 USA

[3] Univ Washington, Dept Elect Engn, Seattle, WA 98195 USA

[4] UW Med Informat Technol Serv, Box 359968,325 Ninth Ave, Seattle, WA 98104 USA

[5] UW Med Ctr Scholarship Patient Care Qual & Safety, Seattle, WA USA

[6] Univ Washington, Paul Allen Ctr, Dept Elect Engn, 185 E Stevens Way,NE AE100R, Seattle, WA 98195 USA

来源：

JOURNAL OF BIOMEDICAL INFORMATICS | 2018年 / 77卷

基金：

美国医疗保健研究与质量局;

关键词：

Electronic health records; Physician documentation; Automatic speech recognition; Hospital care; Workflow; TIME; MOTION;

D O I：

10.1016/j.jbi.2017.12.004

中图分类号：

TP39 [计算机的应用];

学科分类号：

081203 ; 0835 ;

摘要：

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.

引用

页码：91 / 96

页数：6

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