使用语音创建医院进度记录:描述一个与商业电子健康记录集成的移动应用程序和支持系统。

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

机构信息

Department of Medicine, University of Washington, United States; UW Medicine Information Technology Services, Seattle, WA, United States; UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle, WA, United States.

Department of Anesthesiology & Pain Medicine, University of Washington, United States.

出版信息

J Biomed Inform. 2018 Jan;77:91-96. doi: 10.1016/j.jbi.2017.12.004. Epub 2017 Dec 9.

Abstract

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.

摘要

我们描述了一种基于智能手机应用程序的系统的开发和设计,该系统使用语音、商业自动语音识别软件创建住院患者病程记录,使用文本处理来识别语音命令并格式化病程记录,并与商业电子病历系统集成。这个新系统符合医院查房工作流程,并被用于支持一项随机临床试验,以测试使用语音创建病程记录是否可以提高病程记录的及时性、记录质量以及医生对病程记录创建过程的满意度。该系统共创建了 709 份病程记录,这些记录被放置在相应患者的电子病历系统中。从按下“发送”按钮到格式化的病程记录出现在收件箱中的中位数时间为 8.8 分钟。该系统通常非常可靠,受到医生用户的欢迎,并且是安全的。这种方法提供了一种替代键盘和模板的方法来创建病程记录,可能会吸引那些喜欢语音输入而不是打字的医生。

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