by Dana Hinesly

Taking another look at turning voice into data.

Almost since their creation, speech recognition (SR) programs have been overestimating their capabilities, fascinating casual observers but aggravating those hoping to benefit from their claims.

"To this day, we suffer from the over-promised, underdelivered technology, primarily because the applications are very hardware intensive—and the desktop of ten years ago couldn't cope to deliver the accuracy that had been demonstrated and that people expected," explains Nick van Terheyden, MD, chief medical officer of Philips Speech Recognition Systems (Atlanta). The company's SpeechMagic speech-enables the medical IT solutions of leading international healthcare companies, such as Agfa Corp (Ridgefield Park, NJ), Sectra (Linköping, Sweden), Eastman Kodak Co's Health Group (Rochester, NY), and Philips Medical Systems (Andover, Mass). Also, the software is used by more than 200 integration partners in the Philips global network, such as Crescendo Systems Corp (Laval, QC), Dolbey (Concord, Ohio), Epic Systems Corp (Verona, Wis), Health Care Technology (Marietta, Ga), and MedQuist Inc (Mt Laurel, NJ).

Although the seamless and perfect SR systems portrayed in movies and on television are still more fiction than science, the technology has progressed in recent years by leaps and bounds, thanks to both improved algorithms and computer processors capable of the speeds required to run them.

Making Good on a Promise

The past few years have seen a surge in the adoption of SR programs by medical professionals, for a number of reasons. One significant motivator has been the simultaneous decrease in the number of qualified medical transcriptionists and a steady increase in the demand for patient documentation. This shift in available resources has had an undeniable impact on the dictation-to-completed-report turnaround that radiologists can promise.

Matthew J. Bassignani, MD, medical director for RIS and medical director of the University of Virginia (UVA) Imaging Center (Charlottesville, Va), has firsthand experience with this predicament. When he came to the center 5 years ago, SR had yet to be introduced into the facility—and the situation was dire.

"We just couldn't hire enough transcriptionists to handle the 325,000 studies that we did every year, and we had a three-week turnaround time, most of which was spent waiting for transcription," Bassignani says, adding that the facility's radiologists decided during a faculty meeting that change was inevitable. "We realized that none of us could look our clinical colleagues in the face or claim that we were performing any sort of service, because it was taking so long for us to produce the reports."

Another driving force behind growing SR adoption is the resurgence of interest in developing a truly comprehensive and valuable EMR. As government initiatives work to develop protocols and standards, SR manufacturers are creating software that will usher in this electronic future.

"The only way we can enable access to the information in the EMR is to digitize it, and if you can automate the data-gathering process—using speech as one of the enablers—you'll move the EMR to be the central key repository of patient information that clinicians can act on and use," says van Terheyden. "This type of accessible database is essential, because medicine in its current form is unsustainable; the idea that the physician can be the font of all knowledge and manage the whole process without any technology is completely unrealistic."

Perhaps the single biggest reason that more people have taken to SR programs is the most obvious: They actually work now. Not only is accuracy improving—many programs boast rates of 99%—but the software is being rolled into comprehensive solutions designed to streamline the physician's entire job.

Hesitate No More

While they likely dream of an overarching, data-management SR program, radiologists are creatures of habit—they are human, after all—and many bristle at the prospect of the change in workflow this type of system brings with it.

"It is change, but you have to see the benefits and the value that the change will bring," says Andrew W. Litt, MD, associate professor and vice chairman of financial affairs in the department of radiology at New York University Medical Center. "I think this technology is an absolutely critical part of providing good radiology service today, because radiologists are here to serve other physicians—and the better we serve them, the more we contribute to the overall healthcare of their patients." At Litt's facility, radiologists access SR technology through the RadWhere Suite of software from Commissure Inc (New York).

Once an SR program is in place, the changes to workflow are immediately apparent, turning today's standard approach on its head. Instead of simply recording audio and sending it off for transcription, dictating with SR means that the report is converted directly into an electronic document right in front of the radiologist's eyes. Necessary edits are made, and the report is electronically signed and forwarded to the referring physician—all in the same sitting.

"This self-edit approach—what we call ‘once and done'—gives the provider complete control," says Don Fallati, senior VP of marketing for Dictaphone Corp (Stratford, Conn), recently acquired by Nuance. "We've put a lot of work into making the completion process as comfortable as we possibly can, increasingly using voice commands to navigate through and make changes to the document."

To help speed through these additional steps, SR solutions include tools that can actually shorten the dictation process, such as preset templates and "trigger" words that, when spoken, insert entire blocks of copy into a report. Making use of these shortcuts can help clinicians dictate even faster than real time, because they're able to avoid repeating "boilerplate" copy.

"We call them standardized reports, and I use them all the time so I don't keep dictating the same things over and over," says Paul M. Williams, DO, diagnostic radiologist at Northeast Regional Medical Center (Kirksville, Mo). "Also, if there's something in the template I don't like or if there's something I want to add, I can easily change it."

MedQuist supplies the dictation, transcription, SR, and coding systems used by the team at Northeast Regional.

Benefits Beyond the Obvious

Radiologists experienced with SR technology are quick to point out that the system's greatest benefits go well beyond its ability to circumvent delays due to medical transcription.

"When there's even 24 hours' delay between dictating the report and getting it back from the transcriptionist, all you are really doing is grammar checking—because if, for instance, I said ‘right' and I should have said ‘left,' I'm not going to remember that a day later," UVA's Bassignani says. "Doing the report in real time means that I've definitely cut down on those errors."

Not only are reports becoming more accurate, but they also are being delivered with impressively fast turnaround times. "For patients who go directly from our imaging center to their doctor's office, we expedite reports and deliver them within one hour," Bassignani explains. The standard distribution time between the study's completion and when referring physicians have reports in-hand is less than 22 hours. "Our practice has completely changed with speech recognition, and we're now getting referrals from physicians from outside UVA. Clinicians in the area look at our imaging center as the preferred place to send patients," he says.

This type of service also can translate to a dramatic reduction in phone calls from referring physicians, who no longer have to spend time trying to track down results from radiology. Phone calls aren't eliminated entirely with referring physicians receiving reports promptly; however, it means that when the phone does ring, it's for a reason.

"I don't get phone calls anymore about normal or minimal-abnormality reports," NYU's Litt observes. "I get more focused calls, so I'm spending my time focusing on patients where there's really something significant to talk about; it's much more of a consultative type of relationship."

Radiologists at the UVA Imaging Center have noted a similar change since implementing SR technology.

"I used to get a call about every single CT scan, and that's dropped off a lot," Bassignani recalls. "Now when I get calls, it's a clinician with a question about my report, which is all value-added, because that's my role: I'm a consultant to the clinician."

Reducing clerical duties and increasing the speed of reporting also can help radiologists avoid becoming superseded by technology that makes images available to any clinician with Internet access.

"It doesn't do a lot of good for me to interpret the study if nobody knows about it," Litt says, expressing the growing concern shared by many radiologists that referring physicians are obtaining their images and moving forward with treatment before the report arrives. "There is value in my being able to interpret the study and communicate those results to another physician so he or she can make whatever management or therapy decisions are required."

Holding Out

No matter how good SR software becomes, it will never be ideal for everyone. To benefit from SR technology, users must be able to speak clearly—heavy accents are not as problematic as poor diction—and they need to be able to follow the standard rules of grammar. Also, ideal candidates are comfortable with computers, but even "computer-phobic" individuals can succeed with SR, just with a bit more coaxing.

"You must have a physician champion, someone who will keep the faculty involved, letting them know what's coming and keeping them engaged, so that they feel like they're a partner and not that it's happening to them," advises Bassignani, who spearheaded the effort to bring Dictaphone's PowerScribe for Radiology to his facility. To build interest in the new software, Bassignani sent his colleagues a series of e-mails to provide some tips and tricks that could be used with the SR program. "When PowerScribe was installed and the doctors attended training, they already had some familiarity with the program and which features they wanted to learn more about."

An Ever-Growing Technology

The success that many radiologists are seeing with SR has caught the attention of others in the medical community, from general practitioners and cardiologists to orthopedists and mental health professionals. But the transition won't be easy, and arriving at the accuracy rates comparable to those experienced by radiologists will take time.

"As you enter a much more complex, expanded domain—general medicine being a great example—where you can be talking about many different body systems and in different ways," Philips' van Terheyden says, "it's much more challenging. Speech recognition is a statistical process, and we improve that statistical model with more data. So as we accrue more data and go through a process of applying corrections, those models get refined and start to become very accurate."

Charting and other required documentation presents a unique challenge. Simply converting voice to text isn't enough when dealing with an entire patient history and care record. Currently, Philips is fine-tuning a program that allows physicians to dictate "freestyle" while the software analyzes the meaning of his or her speech, assigns value to what is said, and automatically populates the correct section of the medical report. Dictaphone also is tackling this challenge with what it calls natural language processing (NLP).

"NLP reads text and understands it while attempting to deal with the ambiguities of language, noting, for example, the difference between having been prescribed a medication and being allergic to it," Fallati says. "The data extraction is tuned to the top four most sought-after pieces of information by caregivers: medications, allergies, procedures, and problems."

Both systems operate on a similar philosophy: Words without meaning are useless in today's medical environment. Assigning contextual value to content and designing a program to understand the physician's intended meaning by discerning the fine distinctions inherent to spoken communication moves the idea of easily accessible patient information much closer to reality.

"It represents the transition from interest in technology to real, useful, valuable support of clinical activity, which is essential if we're going to deliver high-quality care," says van Terheyden.

Clinicians already sold on SR technology are eager for such advances and have a detailed wish list for future SR programs—including the addition of drafting-type features so that attending physicians could educate residents by returning "edited" studies; SR-generated files with automatically assigned ICD-9 coding; and SR systems tightly integrated with the RIS/PACS, allowing it to offer such features as automatically loading previous study images or providing one-click access to the patient's medical record.

Without a doubt, these types of fundamental shifts in the aim of SR technology will prove to be a daunting and time-consuming task—but one that manufacturers believe is realistic and most likely just around the corner.

Dana Hinesly is a contributing writer for Medical Imaging.