Voice Recognition for Nurses 1

A VOICE RECOGNITION SOLUTION FOR NURSING DOCUMENTATION

A Voice Recognition Solution for Nursing Documentation

By Ryland Hamlet, RN

October 1, 2008
 Voice Recognition for Nurses 2

Executive Summary

Physicians have been using voice recognition since the late 1990s in the emergency room (ER).

Nurses, on the other hand, do not use the technology. With nurses spending up to 19% of their

time documenting, the benefit of using voice technology is great. Voice recognition could be

used to reduce the time needed for nurses and increase the accuracy of nursing documentation.

The problem in attaining these improvements is as follows:

The problem is the error rate of VR enabled nursing documentation may create

unacceptable work for nurses.

The purpose of this paper was to analyze the current state of voice recognition, the future

direction, and determine the impact of the future on nursing documentation. The goal of the

analysis was to recommend a solution to the problem.

The current state of VR leaves much to improve, especially with respect to accuracy. VR is

currently between 93% and 98% accurate. This may cause unacceptable rework for nurses in

fixing recognition errors. In the future, there will be improvements that will positively impact

nursing documentation. Increased accuracy is the main improvement. The impact is less errors

and time needed to fix errors. The recommendation is to change nursing documentation to

utilize steps similar to used by dictation services. Taking advantage of VR will help realize the

goal of saving time and increasing accuracy.

 Voice Recognition for Nurses 3

Table of Contents

Executive Summary.................................................................................................2

Table of Contents.....................................................................................................3

A Voice Recognition Solution for Nursing Documentation.....................................5

Discussion and Analysis......................................................................................5

Current State of Voice Recognition. VR has come a long way since the VIP 100

system of the early 1970s (Weston, 2000). Until recently, small vocabulary and speaker

dependency was the only type of VR. Increased vocabulary beyond numbers or small

words was not possible due to lack of processing power. With today’s Pentium IV

Processor ®, vocabulary has increased from ten words, in the 1970s, to ten’s of thousands

of words today. Not only are vocabularies larger, VR driven systems are now speaker

independent. Figure 1 depicts the past and current state of VR with respect to vocabulary

and speaker independence. With speaker independence a user no longer needs to “train” the

system prior to use.......................................................................................................6

The Problem for Nurses. The problem with using VR in nursing is not with

vocabulary or the independence. The problem is the accuracy. Today’s commercially

available VR software “claim an accuracy of up to 98% of speech recognition at natural

speech rates” (Al-Aynat & Chorneyko, 2003, p. 721). This may sound acceptable for the

ER or for a Radiologist who have transcriptionists that review and correct dictated patient

reports. This review process can occur up to one week later, since the report is not needed

immediately. For nurses, the review and edit work created by the “true” accuracy of 93% or

94% may be overwhelming (Al-Aynat & Chorneyko, 2003, p. 723). Nurses spend up to

19% of their time, or two hours per day, on documentation (Korst et al., 2003). This means

that 1.2 in 100 words spoken into the patient’s chart would need editing. Anyone who has

proof read and corrected a school paper knows reviewing and editing two hours worth of

documentation could take another two hours. Additionally, unlike physicians who dictate in

relatively quiet backrooms, nurses generally document at a noisy nurses station.

 Voice Recognition for Nurses 4

Background noise further decreases the accuracy of VR and the amount of potential edit

work for nurses. The problem with nurse use of VR can be summarized in one statement: 7

The problem is the error rate of VR enabled nursing documentation may create

unacceptable extra work for nurses..............................................................................7

Future Direction. The future direction of VR related to nursing documentation may

help understand how to solve this problem. For VR to become a mainstream, everyday

technology for nurses, vendors must fix the issue related to edit rework. The future

direction does hold promise. Below is a list of features being addressed by vendors in the

near future:...................................................................................................................8

Forecasted Impact. The future direction may help solve the problem of rework.

Improving the accuracy, for example, is very important. Unless the errors, however, can be

completely eliminated, the additional work needed to find and fix the documentation error

will remain an issue. Reducing the effect of background noise may reduce some of the

errors. It may not reduce the time needed for nurses to edit the errors. A module talking

back to the nurse may help in reducing errors. That is, when a word sounds similar to

another, the VR module can ask the nurse what was meant. This feature may reduce the

error rate, but may slow the documentation speed. Overall, the future direction of VR may

reduce errors, but may not eliminate the rework.........................................................8

Recommendation and Conclusion.......................................................................9

References Cited....................................................................................................11
 Voice Recognition for Nurses 5

A Voice Recognition Solution for Nursing Documentation

In Cramming More Components onto Integrated Circuits, Gordon Moore wrote that “a large

circuit can be built on a single wafer” (Moore, 1965). The wafer Moore referred to was the

integrated circuit (IC), the brain and nervous system of the personal computer. Moore theorized

that a “doubling of transistors every couple of years” is possible. His theory known as Moore’s

Law is the basis for Intel’s achievements. Since he co-founded the company, Intel has doubled

the processing power of their IC’s every few years (www.intel.com, 2004). Without the Intel

processor, voice technology, specifically voice recognition (VR) may not exist. VR is being used

successfully in many industries including healthcare. Physicians, for example, have embraced

VR as a time saving way to document. VR for nurses, the subject of this analysis, still has room

for significant improvement. This paper analyzes the use of voice technology, particularly voice

recognition (VR) for nurses. The paper discusses and analyzes the current state of VR to develop

a problem statement. The future direction of VR is analyzed with the forecasted impact on

physicians. A recommendation and conclusion is made based on the analysis.

Discussion and Analysis

Physicians have been using voice recognition since the late 1990s in the emergency room (ER).

ER physicians use VR enabled dictation software which type spoken text directly into the

patient’s electronic medical record. A study in the American Journal of Emergency Medicine

concluded that dictating and transcribing ED medical records decreases the time required for

documentation, improves record legibility and quality (Witt, 1995). Additionally the turnaround

time, the time need for the transcription service to produce the final report, was much better

using VR (Zick & Olsen, 2001). Nurses, on the other hand, chart more than physicians, but

rarely have the opportunity to use VR. The reason for this may be seen in an analysis of the

current state of VR. This analysis may help discover not only the problem, but a solution for

nurses’ lack of VR use. VR promises to reduce the time needed for nursing documentation and

increase accuracy as it has with physician dictation.

 Voice Recognition for Nurses 6

Current State of Voice Recognition. VR has come a long way since the VIP 100

system of the early 1970s (Weston, 2000). Until recently, small vocabulary and speaker

dependency was the only type of VR. Increased vocabulary beyond numbers or small words was

not possible due to lack of processing power. With today’s Pentium IV Processor ®, vocabulary

has increased from ten words, in the 1970s, to ten’s of thousands of words today. Not only are

vocabularies larger, VR driven systems are now speaker independent. Figure 1 depicts the past

and current state of VR with respect to vocabulary and speaker independence. With speaker

independence a user no longer needs to “train” the system prior to use.

Figure 1: Types of VR Technology (Weston, 2000)

 Voice Recognition for Nurses 7

Tellme, the 411 directory service, is an example of a speaker independent VR system. Tellme

pioneered VoiceXML based directory assistance with the launch of 1-800-555-1212 in July of

2001 (www.tellme.com, 2004).

The Problem for Nurses. The problem with using VR in nursing is not with vocabulary

or the independence. The problem is the accuracy. Today’s commercially available VR software

“claim an accuracy of up to 98% of speech recognition at natural speech rates” (Al-Aynat &

Chorneyko, 2003, p. 721). This may sound acceptable for the ER or for a Radiologist who have

transcriptionists that review and correct dictated patient reports. This review process can occur

up to one week later, since the report is not needed immediately. For nurses, the review and edit

work created by the “true” accuracy of 93% or 94% may be overwhelming (Al-Aynat &

Chorneyko, 2003, p. 723). Nurses spend up to 19% of their time, or two hours per day, on

documentation (Korst et al., 2003). This means that 1.2 in 100 words spoken into the patient’s

chart would need editing. Anyone who has proof read and corrected a school paper knows

reviewing and editing two hours worth of documentation could take another two hours.

Additionally, unlike physicians who dictate in relatively quiet backrooms, nurses generally

document at a noisy nurses station. Background noise further decreases the accuracy of VR and

the amount of potential edit work for nurses. The problem with nurse use of VR can be

summarized in one statement:

The problem is the error rate of VR enabled nursing documentation may create

unacceptable extra work for nurses.

 Voice Recognition for Nurses 8

Future Direction. The future direction of VR related to nursing documentation may help

understand how to solve this problem. For VR to become a mainstream, everyday technology

for nurses, vendors must fix the issue related to edit rework. The future direction does hold

promise. Below is a list of features being addressed by vendors in the near future:

1. Improving the accuracy currently 93% to 98%

2. Reducing the negative effect of background noise

3. Ability to run on low power computers including palmtop device

4. Increased vocabulary from current 60,000

5. VR module asks user clarifying questions

The features will be applied in many creative ways in other industries. Soon, VR will be used in

manufacturing to completely control production lines. VR will also be used in the security

industry as a replacement for lock and key. Applications across multiple fields include replacing

the keyboard as the primary input to computers, cell phones and other alphanumeric based input

devices.

Forecasted Impact. The future direction may help solve the problem of rework.

Improving the accuracy, for example, is very important. Unless the errors, however, can be

completely eliminated, the additional work needed to find and fix the documentation error will

remain an issue. Reducing the effect of background noise may reduce some of the errors. It may

not reduce the time needed for nurses to edit the errors. A module talking back to the nurse may

help in reducing errors. That is, when a word sounds similar to another, the VR module can ask

the nurse what was meant. This feature may reduce the error rate, but may slow the

documentation speed. Overall, the future direction of VR may reduce errors, but may not

eliminate the rework.

 Voice Recognition for Nurses 9

Recommendation and Conclusion

Even with the power of the Intel processor, reducing the error rate to zero may not be possible

with today’s voice technology. The future direction holds some bit of promise. Given the 6%

error rate, and the subsequent rework, a solution must look outside of technology. This solution

must eliminate or nearly eliminate the time needed to review and edit VR produced

documentation errors. One recommendation would be to craft a process that eliminates the

errors altogether. A process similar to the one dictation services uses to review, edit and produce

patient reports for ER physicians may solve the problem. There are significant differences,

however, in the way nurses and physicians chart. Nurses document on more forms and in more

fields than physicians. Any solution would have to take this difference into consideration.

Utilizing a dictation review and edit process that follows the steps below may reduce or

eliminate errors.

Step 1.Nurse records nurses voice recorded notes into voice enabled fields

Step 2.Each field has its on smaller, context sensitive dictionary

Step 3.Each field is recognized in the background with potential errors flagged

Step 4.In-house transcription service fixes errors, by the end of the nurses shift

Step 5.Nurse fixes flagged errors throughout shift and comprehensively at the end-of-

shift

The basis of this process is utilizing VR and people, combined to eliminate errors. By eliminate,

it is meant statistically eliminated at a 99.7% level. Each voice enabled field (Step 1) in the

patient record would have its own VR dictionary (Step 2). The recognition rate would increase

due to the smaller vocabulary. Similarly, the errors would be flagged at a higher percentage.

These errors would be corrected by a transcriptionist, by the end of the nurses shift (Step 4). At

this point a 99.7% accuracy rate is possible (Zick & Olsen, 2001). The nurse double checking by

the end of the shift may increase the accuracy far above the required 99.7% as required to solve
 Voice Recognition for Nurses 10

the problem.

Gordon Moore’s contribution has revolutionized not only the computer world, but also the

healthcare industry. Without the seemingly endless increased processing power of the IC

predicted by Moore, voice technology may not be possible. Even with this processing power,

nurses still do not use voice recognition. The problem is VR is still not accurate enough. The

amount of rework needed to fix errors is unacceptable. To solve the problem requires a process

to eliminate the rework altogether. This paper analyzed the current state of VR to help discover

the cause of the problem. VR’s future direction was reviewed in hopes of discovering a solution.

The recommendation is to change nursing documentation to utilize steps similar to used by

dictation services. The updated process may finally help nurses use voice recognition.
 Voice Recognition for Nurses 11

References Cited

Al-Aynat, M. A., & Chorneyko, K. A. (2003). Comparison of Voice-Automated Transcription

and Human Transcription in Generating Pathology Reports. New Technology in

Laboratory Medicine, 127, 721-725.

Intel Corporation. (n.d.). Intel - Silicon - Moore's Law. Retrieved April 25, 2004, from

http://www.intel.com/research/silicon/mooreslaw.htm

Korst, L. M., Eusebio-Angeja, A. C., Chamorro, T., Aydin, C. E., & Gregory, K. D. (2003).

Nursing documentation time during implementation of an electronic medical record.

Journal of Nursing Administration, 33(1), 24-30. Retrieved April 25, 2004, from

http://web13.epnet.com/citation.asp?tb=1&_ug=dbs+cin20%2Ccih+sid+3CEE9380%2D

30FF%2D467B%2DBA0A%2D6F6E332B0C03%40sessionmgr6+DC91&_us=dstb+KS

+hs+0+or+Date+ri+KAAACBVB00089189+sl+%2D1+sm+KS+ss+SO+C070&_uso=db

%5B1+%2Dcin20+db%5B0+%2Dcih+ex%5B0+%2Dproximity+hd+0+op%5B0+%2D+

st%5B0+%2DNurse++and++Charting++and++%22documentation++time%22+tg%5B0+

%2D+540F&fn=1&rn=1

Moore, G. E. (1965). Cramming more components. Electronics, 38(8). Retrieved April 25, 2004,

from ftp://download.intel.com/research/silicon/moorespaper.pdf

Tellme Networks, Inc. (n.d.). About Tellme. Retrieved April 25, 2004, from

http://www.tellme.com/about.html

Weston, T. (2000, November 15). History of voice recognition. Retrieved May 25, 2004, from

http://florin.stanford.edu/~t361/Fall2000/TWeston/history.html

Witt, D. J. (1995). Transcription services in the ED. American journal of emergency medicine,

13(1), 34-36.

Zick, R. G., & Olsen, J. (2001). Voice recognition software versus a traditional transcription

service for physician charting in the ED. American Journal of Emergency Medicine,

19(4), 295-298.