Voice Recognition Commands in Clinical Medicine

Thorough but honest notes

Aside from the obvious efficiency of voice recognition dictating over hand typing, perhaps its biggest advantage is the flexibility and time-saving resulting from the use of macros and templates. Adding to this is the ability to insert a templated object or text simply by speaking the name assigned to the command, without searching on a menu or using a keyboard command. On the other hand, over- or inappropriate use of templates may pull the physician into the realm of "padded" notes or perhaps even unintended fraud. As an example, the use of "boilerplate" notes, with major or essential aspects of the history and physical exam already completed opens the door to potentially inaccurate or fraudulent documentation. While it might be intended that material will be cut from such boilerplate text, in practice this might not actually occur.

It is essential, therefore, to use templates in a manner that allows you to save time in documenting things that were actually heard, observed or said, but not to get drawn into the realm of "fantasy documentation".

The physical examination is probably the easiest place to let boilerplate text go too far. While initially I created commands that would add a complete generic exam, after using these for a while I realized that it was sometimes tedious to go through the exam and remove or change areas that did not correspond with what was actually observed, and occasionally found myself thinking "well there probably wasn't any liver enlargement" even though I hadn't specifically checked for it. Big mistake! Notes have to be accurate. The question is how can you do this and still save time in documenting?

Reasonalbe use of speech commands in medical documentation:

Certain things are a set-up for honest, appropriate use of text commands with Dragon.. These include:

• Documentation of the rationale for a treatment or procedure if it applies to a particular patient
• Documentation of counseling to a patient if you mention the same things each time you engage in this discussion
• Documentation of the risks of a procedure if you discuss this the same way with each patient
• Documentation of individual aspects of the physical examination if this aspect of the exam is done in the same way with every patient
• Insertion of graphical items such as logos, document headers, signatures, etc.
• Insertion of forms or templates for notes and correspondence which can be further modified once inserted
• Mailing addresses of referring physicians and others with which your frequently correspond
• Lot, lots more

Does this mean you can create a command for the entire presentation of a person presenting with a clinical condition? Almost certainly not! Many commercial vendors provide exactly such a template in which the "typical" upper respiratory infection presentation or presentation for another condition is provided lock, stock and barrel, and you simply fill it in by choosing it from a list or with a dictation command. If it really doesn't matter whether the fever was 101 or 106, perhaps this wouldn't matter. If the presence of a stiff neck and macular rash didn't provide diagnostically and prognostically important information, then again it might not matter. But I would argue that it is a physician's ability to detect the nuances of one's history and physical findings that set him or her apart from a computer diagnosis. So we can't allow the use of templates to gloss over, miss entirely, or misstate these nuances.

Examples of honest and helpful commands:

The Examination: In documenting the exam it is helpful to break it down to individual regions or organ systems and to create boilerplate text describing the way you normally examine this area and normal findings. Needless to say you will use this command only if you examined this area and finding were, in fact, normal. As you go through your exam, you will not say the command for any area you did not examine or find normal. Areas that were found to be abnormal you will individually and with appropriate detail describe. As an example, I have the following commands set up for normal aspects of the exam which I may or may not choose:

• "Normal head"
• "Normal neck"
• "Normal lungs"
• "Normal heart"
• "Normal abdomen"
• "Normal extremities"

For each command I have assigned a sentence or two describing a normal exam of the area and assuming normal findings. If I actually examined each area and found no abnormalities, the accumulation of these commands, one spoken after the other, would appear like this:

"Head exam was generally normal. There was no scleral icterus or corneal arcus. Neck was supple and without jugular venous distension, thyromegally, or carotid bruits. Carotids were easily palpable bilaterally. Lungs were clear to auscultation and percussion, and with normal diaphragmatic excursion. No wheezes or rales were noted. Cardiac exam revealed the PMI to be normally situated and sized. The rhythm was regular and no extrasystoles were noted during several minutes of auscultation. The first and second heart sounds were normal and physiologic splitting of the second heart sound was noted. There were no murmurs, rubs, clicks, or gallops. Abdominal exam revealed normal bowel sounds. The abdomen was soft, non-tender, and without masses, organomegally, or appreciable enlargement of the abdominal aorta. Examination of the extremities revealed easily palpable radial, femoral and pedal pulses. There was no cyanosis, clubbing or edema."

In reality, I usually always have a different cardiac exam to dictate, so it's rare that I use the command "Normal Heart". And I don't always feel for all the distal pulses, so I may either leave off the "Normal Extremities" command or simply dictate "Extremities were without edema" if the exam was somewhat cursory. The point is that in the matter of 20 seconds I have documented a completely accurate and honest exam without having to hand type it or even dictate it in it's entirety.

Helpful Hint: Even with voice recognition, any opportunity to save words will minimize vocal cord strain.

Helpful Hint: When you prepare the commands for small snippets of text like this that will fit together to make a paragraph, be sure build your command with a couple of spaces before the text begins to allow proper spacing from the prior text. Also, be sure to click on the "Plain text" box in the bottom right of the Command Editor box. This will assure that any text will be inserted with the same text as being used at that point in your document, rather than any specific text

Documentation of Discussions: In my field (Cardiology), patients are often transferred to our inpatient floor for ultimate cardiac catheterization and usually come for one of several reasons, including post-infarction angina, unstable angina, or the treatment of an acute ST segment elevation MI. In each of these cases the rationale for performing the procedure is well accepted and easily stated. So rather than typing the text outlining what is a standard argument, why not create a command for each of these situations? Here's an example of what I've used:

For the patient presenting with an acute coronary syndrome, in my discussion portion of the note my command "ACS Cath" will add the following discussion:

"The combination of typical cardiac symptoms and enzyme elevation in this patient is consistent with the diagnosis of acute coronary syndrome or non-ST segment elevation MI (NSTEMI). Although this situation could be dealt with conservatively, several studies (most notably the TACTICS-TIMI-18 Study - NEJM 2001;344(25): 1979-87) have suggested a reduction in major cardiac events with an invasive strategy utilizing routine catheterization and revascularization as appropriate. For this reason, early catheterization is recommended in this patient."

For the patient presenting with stable angina in a progressing pattern or with symptoms leading to significant lifestyle limitations, my command "Stable Angina Cath" inserts the following text:

"Given the extent of this patient's anginal symptoms and resulting lifestyle limitations, and with the hope of identifying anatomy which will be amenable to either catheter-based or surgical intervention, it is reasonable and recommended that further evaluation with heart catheterization take place."

Procedural Consents: If it is your practice to use a standardized discussion in reviewing the risks of a procedure, it is both smart to document the details of this discussion and efficient to do so using templated text. Examples include templates I use to document discussions about heart catheterization and cardioversion.

The commands "Cath Risk" or "Cardioversion" risk will insert one of the following:

The indications, expected benefits and potential risks of heart catheterization were reviewed in detail with the patient. The potential for death, heart attack, stroke, kidney failure, hemorrhage, allergic reaction, vascular complications and infection were reviewed in detail. The possibility of stenting and other percutaneous intervention, with associated risk, was reviewed. The possible need for emergent coronary artery bypass surgery was reviewed. After a discussion about the above, and having answered all questions posed, the patient was provided with a consent which was reviewed and signed.

The indications, expected benefits and potential risks of cardioversion were reviewed in detail with the patient. The potential for stroke, skin burn, aspiration and bradycardia requiring placement of a temporary pacemaker were reviewed in detail. After a discussion about the above, and having answered all questions posed, the patient was provided with a consent which was reviewed and signed.

Templates for Graphic Images: It is surprising how often the insertion of graphic images comes in handy in the course of things. The following are some templates which I have found useful in the course of correspondence and note generation:

• Insert Logo: Inserts the DHMC Logo
• Insert Header: Inserts DHMC Logo with my personalized address information
• Insert Signature: Inserts a digital version of my signature

How to Obtain Templates and Macros:

In general terms you have the choice of purchasing pre-made templates and macro or building them yourself. If the sophistication of your needs is not huge or if you and your colleagues prefer to have "home grown" templates, the process is not at all difficult and involves no more than pasting into a new command window the appropriate text and giving it a simple and intuitive name. In my own experience, remembering the name may be the biggest challenge.

If you prefer to purchase templates, either for full notes or portions of notes, you might try some of the following sources:

• Speech Recognition Solutions: A spin-off of the site you are currently visiting, this site includes some hints of building commands, sample commands to build or download, and a variety of pre-made medical exam templates, including note templates and exam snippets.
  
• MedTemps: Here's a vendor created description: "MedTemps is a collection of HCFA and AMA compliant macros and templates for speech recognition. Once installed into the speech recognition program of choice MedTemps becomes a part of the program. It allows physicians to work the way in which they are accustomed to within their favorite speech recognition program. MedTemps is compatible with IBM Via Voice and Dragon Naturally Speaking Products. Physician Written with strict adherence to HCFA Guidelines. Installation is a snap by following the detailed instructions that come with the package." This product is available from a number of vendors.
  
• Knowbrainer: This is a source of tens of thousands of macros to perform a gazillion tasks on your computer by voice command. I have never tried them, but it seems Knowbrainer has an extensive and loyal following.
  
• Voiceability: A description from the company: "VoiceAbility provides medical templates and macros which can be used with Microsoft® Word, or within an electronic medical record program. By using specific templates or skeletal templates with a combination of macros for the normal or negative portions of the review of systems and physical examination and actual dictated text for the portions of your reports that are not normal or routine, you can generate authentic reports with documentation that reflects the services actually performed with much less likelihood of documenting something you didn't do."

Building Your Own Commands

Although it may seem daunting at first and better the domain of programmers, Dragon NaturallySpeaking is designed with the expectation that regular users can and should create customized macros. It is, truly, through the development of such macros that Dragon reaches its true potential. Until you try it, you won't appreciate how simple it is!

For more information on building macros, please visit my Macro Construction Page.