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语音识别软件和电子精神病学进展记录:医生的评价和偏好。

Speech recognition software and electronic psychiatric progress notes: physicians' ratings and preferences.

机构信息

Information Management Group, Centre for Addiction and Mental Health, 1001 Queen St, West, Toronto, Ontario, M6J 1H4, Canada.

出版信息

BMC Med Inform Decis Mak. 2010 Aug 25;10:44. doi: 10.1186/1472-6947-10-44.

Abstract

BACKGROUND

The context of the current study was mandatory adoption of electronic clinical documentation within a large mental health care organization. Psychiatric electronic documentation has unique needs by the nature of dense narrative content. Our goal was to determine if speech recognition (SR) would ease the creation of electronic progress note (ePN) documents by physicians at our institution.

SUBJECTS

Twelve physicians had access to SR software on their computers for a period of four weeks to create ePN.

MEASUREMENTS

We examined SR software in relation to its perceived usability, data entry time savings, impact on the quality of care and quality of documentation, and the impact on clinical and administrative workflow, as compared to existing methods for data entry.

DATA ANALYSIS

A series of Wilcoxon signed rank tests were used to compare pre- and post-SR measures. A qualitative study design was used.

RESULTS

Six of twelve participants completing the study favoured the use of SR (five with SR alone plus one with SR via hand-held digital recorder) for creating electronic progress notes over their existing mode of data entry. There was no clear perceived benefit from SR in terms of data entry time savings, quality of care, quality of documentation, or impact on clinical and administrative workflow.

CONCLUSIONS

Although our findings are mixed, SR may be a technology with some promise for mental health documentation. Future investigations of this nature should use more participants, a broader range of document types, and compare front- and back-end SR methods.

摘要

背景

本研究的背景是在一家大型精神卫生保健机构中强制采用电子临床文档。由于密集叙述内容的性质,精神科电子文档有其独特的需求。我们的目标是确定语音识别 (SR) 是否会减轻我们机构医生创建电子进展记录 (ePN) 文档的难度。

受试者

十二名医生在其计算机上使用语音识别软件进行了为期四周的 ePN 创建。

测量

我们研究了语音识别软件在可用性、数据录入时间节省、对护理质量和文档质量的影响,以及对临床和行政工作流程的影响,与现有的数据录入方法进行了比较。

数据分析

使用一系列 Wilcoxon 符号秩检验来比较 SR 前后的测量值。采用定性研究设计。

结果

完成研究的十二名参与者中有六名(五名仅使用 SR,一名使用手持数字录音机的 SR)赞成使用 SR 来创建电子进展记录,而不是他们现有的数据录入方式。在数据录入时间节省、护理质量、文档质量或对临床和行政工作流程的影响方面,SR 并没有明显的好处。

结论

尽管我们的发现喜忧参半,但 SR 可能是一种具有一定潜力的心理健康文档记录技术。未来对这种性质的研究应使用更多的参与者、更广泛的文档类型,并比较前端和后端的 SR 方法。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/748c/2939584/8e03548d5b37/1472-6947-10-44-1.jpg

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