Go with the flow: optimizing voice recognition to streamline workflow

1. Go with the flow: optimizing voice recognition to streamline workflow Jeffrey Chenoweth MD Saint Louis VAMC Kim Wilson MD Tucson VAMC

2. Voice recognition to streamline workflow Jeffrey Chenoweth MD Saint Louis VAMC Kim Wilson MD Tucson VAMC

3. Voice recognition to streamline workflow Driving forces behind VR Pushback � VR controversy VR development Case study � VR implementation PACS setup and reporting with VR Kim Wilson MD Practical points for improving Radiologist workflow Future development of VR

4. Radiology reporting Basics unchanged in last century Product not images but report Communication to improve patient care Penultimate step in Radiology process Final step -- clinician action

6. Why VR? Absence of skilled transcriptionists? Transcription cost? Probably not

7. Why VR? Improved report turnaround time Fewer report errors

8. Why VR? Transcription turnaround time Cassette tapes: week � 10 days Digital dictation: hours � 3 days VR: minutes Decreases calls for preliminary read Clinicians expect immediate report availability

9. Why VR? Improved report turnaround time ? Improved patient care Makes the Radiology report relevant

10. Why VR? Problems with the traditional report correction editing process Outside normal Radiologist workflow Disruptive Time consuming

11. Why VR? Error prone traditional report correction � editing process Time lag forgetfulness Grammar checking vs. content errors Right � left errors Date errors DHCP blue screen daze After 50 + reports, how closely are you reading the report?

12. Why VR? Report completion while image is in front of Radiologist Immediate error correction Once you�re done, you�re done Immediate report availability

14. VR controversy

15. VR controversy � Radiologist�s view Increased dictation time Increased error rate vs. good transcriptionist Removes focus on images

16. VR controversy � accuracy rate Is 95% acceptable? 90% of all reports have errors prior to sign off 10 % of reports have errors with transcriptionists J Digit Imaging Jun 2007

17. VR economically justified? Decreased Radiologist productivity 50% longer dictation time 24% shorter reports J Digit Imaging Jun 2007

18. VR � economically justified? Replacing lower paid transcriptionists with highly paid physicians Greater Radiologist productivity ? transcriptionists more cost effective than VR �� which course of action makes the most economic sense� is not always obvious.� JACR 2007; 4: 890

19. VR � two decades of controversy �Has considerable potential in the future� at present has limited function and definitely needs more technical improvement.� Radiology Nov 1988; 169: 580 �� voice recognition systems are currently not ready for prime time.� JACR 2007; 4: 667

20. VR � two decades of controversy �Speech recognition systems are used today in more than 1,000 radiology departments and are experiencing a growth rate typical of modern enabling technology.� JACR 2007; 4:670

23. Evolution of Radiology reports Paper reports Electronic reports

24. Transcriptionist model � 1 Tapes Batch transcription Batch correction, signature

25. Transcriptionist model � 2 Digital transcription pool In-line transcription Batch correction, signature

26. Computer data acquisition systems Mark-sense forms GE RAPORT AJR 1977; 128: 825

27. Computer data acquisition systems Microcomputers � CLIP Harvard Numeric codes for reporting Radiology 1979; 133: 349 Recognition of spoken numeric codes Radiology 1981; 138: 585

28. True VR � Kurzweil system 1987 Reported by several New England hospitals (including Boston VAMC) 1,000 word lexicon 5 sections by anatomy or subspecialty Radiology 1987; 164: 569.

29. True VR � Kurzweil system 1987 Able to dictate a report 88% of the time 12% beyond scope of lexicon Use of macros Dictation time 20% longer

30. True VR � Kurzweil system 1987 Drawbacks Time and attention diverted from film analysis towards interaction with a monitor Increased dictation time proportional to degree of abnormality on film Problems with background noise Problems with repeated interruptions �Has considerable potential in the future� at present has limited function and definitely needs more technical improvement.� Radiology Nov 1988; 169: 580

31. VR � state of the art 1999 Error rate 30% Misrecognition of words Increased dictation time RadioGraphics 1999; 19: 2.

32. VR � today Web architecture Integration with PACS Improved efficiency Decreased errors Improved recognition rates Decreased turnaround time

34. VR case study: Saint Louis VAMC

35. VR drivers PACS implementation Fewer lost films ? More reports required

36. VR drivers CPRS implementation Universal availability of patient chart ? Clinical demand for faster reports

37. VR drivers Problem of preliminary reports Clinical demand Error correction Legal issues

38. VR drivers Transcription problems New contractor (low bidder) Cut and paste errors Variable transcriptionist quality

39. VR drivers Turn around time mandate 90% completion in 48 hours ? successful 95% completion in 48 hours ? excellent Actual far less

40. Analysis of options Hire more Radiologists Full-time Part-time Retired Radiologists Fellows Recruiting difficulties Pay Vacation

41. Analysis of options Improve efficiency of reporting cycle ? VR

42. Proposal for VR system Strong administration support Support for VISN-wide solution Some centers opted out

43. System evaluation Radiologist input Administration ADPAC PACS coordinator IT Literature review

44. System evaluation Vendor demonstrations Radiologist trials Evaluation of administrator functions

45. Survey existing users Most sites only have experience with one system Hard to get good comparisons Your mileage may vary Differences in technical, administrative support for system

46. License issues Per unique user Per workstation Simultaneous users vs. individual user

47. Vendor recommendation and selection

48. Planning Documentation review Site planning

49. Results Report turnaround 90 � 95 % within 48 hours Cost savings

50. VR implementation: lessons learned Plan, plan, plan

51. Lessons learned � project team Identify members PACS administrator Transcription administrator Editors IT Radiologist Dedication essential Time consuming Work closely with vendor Read documentation closely

52. Lessons learned � conference calls Weekly calls Need everyone involved IT Administrators Editors Radiologist Vendor

53. Lessons learned � conference calls Write questions in advance Keep minutes Serves as a resource Complex project, can�t remember everything Document to prevent misunderstandings

54. Lessons learned � installation issues Administrator training critical Get administrator manuals before vendor rep shows up Write questions in advance Take notes

55. Lessons learned � test, test, test Test everything � don�t even think of implementation until this is done Vendor supplied checklist

56. Lessons learned � test, test, test Test system and test accounts Register procedure names and CPT codes Enter orders into Vista Check request entry into VR system

57. Lessons learned � test, test, test Dictate test reports Check for proper upload Test addendums and corrections Input every type of diagnostic code Check parent and descendants

58. Lessons learned � test, test, test Change orders Minimum of 100 test patients Test every Radiologist Include residents Test sending to editor Test telephony

59. Lessons learned � Radiologist champion Change ? resistance Promote system, convince others that this is way to go Upfront buy-in from Radiologists Must see as improving patient care vs. mandate from administration

60. Lessons learned � Radiologist champion Overcome objections �I�m a physician not a transcriptionist!� Help others as one professional to another Keep people going thru rough spots Need close communication with remainder of implementation team Get feedback

61. Lessons learned � Radiologist training Radiologists that have problems generally did not get good training

62. Lessons learned � Radiologist training Must have training schedule for every Radiologist Everyone has dedicated blocks for training, including follow-up Minimum 4 hours with trainer Some may need more attention Follow-up session

63. Lessons learned � Radiologist training Once trained, go cold turkey Continuing support Dealing with non-native English speakers Dealing with poor dictation styles Refresher training

64. Lessons learned � site trainer training Must learn to train new users Critical if residents involver Individual training Sit in on user training sessions

65. Lessons learned � continual QC Continual effort and vital for long-term success Test plan Test telephony Dummy orders uploading

66. Lessons learned � continual QC Pull real reports and monitor for errors Intervention if needed Retraining of dictator Rebuild voice model

67. Lessons learned � continual QC Look in CPRS Report text ok E-signature ok Diagnostic codes

68. Lessons learned � continual QC Monitor continually Uploads Orphan dictations Exams without reports

69. Lessons learned � continual QC Need support contract Keep contacts handy Know who to call

70. Lessons learned � trouble log Take notes for every trouble call to vendor Resource to fix problems on your own Record Day Ticket # Who spoke to Problem How it was resolved Note recurring problem

71. Lessons learned � backup plan Backup VR server? Utilize another transcription contract? Other medical center?

73. PACS setup and reporting with VR Kim Wilson MD Tucson VAMC

75. Radiologist workflow: practical points

76. Goals Increase dictation efficiency Maximize eyes on image

77. Transcription models � read, edit, done Highly recommended Minimize turnaround Make corrections while image is in front of you Once it�s gone you don�t have to deal with it again

78. Transcription models � batch correct, sign Most efficient work flow state? Longer turnaround Error correction more difficult Right � left Dates

79. Transcription models � editor Not recommended Transforms transcriptionist model ? correctionist Inefficient, expensive Maximum turnaround time Must remember to correct and sign reports Editor errors When is it helpful? Non-native English speakers? Poor dictation technique

80. Transcription styles Free dictation Templates and macros

81. Free dictation Advantage Keeps eyes on image Disadvantage More time with editing and corrections

82. Templates � advantages Improved time savings Improved report accuracy Consistent report structure Personally Across department Need agreement among radiologists Facilitates structured reporting BIRADS

83. Templates � disadvantages Takes eyes of the image May forget to delete non-relevant text

84. Templates Especially useful for repetitive boilerplate Biopsy Angiography The patient was placed on the CT table in [<supine> ] position. Initial scans were obtained to localize the [ ]. An appropriate site at the [ ] was marked. The patient was prepped and draped in the usual sterile manner. Local anesthesia was achieved with infiltration of 1% Xylocaine.

85. Template approaches Few general reports Fill in the blanks Default fill in the blanks Many specific reports Case [ ]. [ ] There is no evidence of fracture, dislocation, or bony destruction. [<The joint spaces are within the limits of normal.>] [ < >] Impression: [<Negative examination.>]

86. Templates� itemized reports Lungs: [<normal.>] Pleura: [<normal.>] Mediastinum [<normal.>] Hila: [<normal.>] Other: [< >] Comparison: [<None.>] Impression: [<normal>]

87. Template tricks Standardize template naming convention Modality ? body part ? side, technique

88. Template tricks Make template easy to change on the fly Liberal use of paragraphs Case [ ]. Ultrasound abdominal aorta. Real-time ultrasound examination of the abdominal aorta was obtained in transverse and longitudinal projections. The patient [<does not have an>] abdominal aortic aneurysm. The abdominal aorta measures [ ] cm in maximal diameter. [< >] Impression: [<The patient does not have an abdominal aortic aneurysm.>]

89. Dictation technique Fast ok Must be clear and distinct Think before speaking Know what you want to say No filler sounds

90. Dictation technique Speak in phrases Get a flow Correct in phrases rather than individual words Use complete sentences Use paragraphs liberally

91. Dictation technique Consistent style Keep reports short Don�t number items in impression

92. Dictation technique Dictate � then correct Keep eyes on image Read and correct reports carefully before signing

93. Microphones Proper location Headsets?

94. Environment Noise control Bullpen disruption

95. Monitor layout Open window in admin monitor Don�t continually check transcription Dictate then ? edit Pop-up in admin monitor

96. Monitor layout Separate monitor? VR CPRS Internet window � Google Decision support software? Teaching file software?

97. Training for problem words Case number ? December Pulmonary ? bony Adrenal ? no renal

98. Gotchas Impression: Dictate case number in every report Troubleshooting

99. Gotchas How reports look in VR may not be how report looks in PACS, Vista, or CPRS Line spacing New lines vs. paragraphs

100. Residents Pre-dictation by resident Make corrections and finalize report at time of checking Easy sign-off by attending Drawbacks � templating May not learn elements of a good report

101. Success rules for VR You must want system to work Training the VR vs. VR training you Rule of thirds

103. Future development of VR

104. Improved recognition engines Better accent recognition Better recognition of small words

105. Improved integration of PACS, HIS-RIS Too easy to mark case as read when not Too easy to mark case unread when is read Too easy to hang up report Impression: Too easy to forget to sign off on report

106. Improved grammar checking There Their They�re Two Too To Capitalization

107. Structured reporting Standard lexicons Universal framework for reports Improve readability Minimize style variation between Radiologists Data mining BIRADS

108. Seamless integration of communication Clinical alerts Paging for critical findings Feedback to technologist, QA supervisor

109. Ultimate VR goal: universal recognition

110. Outlook Mailgroup VHA Radiology Voice Recognition