Say that again: 99% accurate

Software developers claim near-perfect precision in speech recognition.

By Neil Zeidenberg

Despite frequent complaints over price, accuracy and training time, physician interest in speech recognition technology is on the upswing. In fact, some vendors have seen their sales to doctors rise as much as 25 percent in the last year.

Speech technology is not exactly new and it’s not exactly perfect. However, in the last two years, software developers say they have produced dramatic improvements – meaning higher accuracy with less training time required.

Better software algorithms are partially responsible for the beefed-up accuracy, along with recent gains in PC performance and power.

Charles Marriott is president of Talk2Me Technology (www.talk2me.com), a Canadian distributor of Dragon NaturallySpeaking and other speech recognition solutions. According to him, fifteen years ago users ran their systems on 486s with 16 MB of memory. “Now, the recommendation is a Pentium IV with 512 megabytes of RAM. It’s a completely different PC and a huge difference in processing power,” said Marriott.

Medical vocabularies are a feature that have vastly improved things for doctors. They contain terminology and common phrases for a wide variety of specialties like cardiology, radiology, pathology, oncology, neurology, gastroenterology, OBGYN, pediatrics, mental health, along with general practice.

Most speech recognition systems also allow doctors to build macros or standard blocks of text, on command. They’re handy for doctors who prepare many letters of the same type. They need only to change dates, names and addresses, symptoms, and diagnosis. The boilerplate is taken care of by the system.

Dr. Alan Brookstone, a family physician in Burnaby, B.C., first tested speech recognition technology in the early 1990s. He says with many good systems on the market, the choice of packages really depends on price and how much time someone is willing to spend training the system.

“It’s improving all the time, but as with most things, it comes down to basic issues. What are you willing to pay and how much effort are you willing to make?”

One year ago Dr. Martin Pham-Dinh, an ER physician at Centre hospitalier des Vallees de l’Outaoais, in Gatineau, Que., paid about $5,000 for NaturallySpeaking v.7 French Professional and a Toshiba M200 Tablet PC.

“The entire system was very expensive, but improved productivity and increased quality of care in the long run make it worthwhile.” The use of voice commands to create short cuts allows Dr. Pham-Dinh to complete his patient charts more quickly. When we asked him if he had any suggestions for product improvements, Dr. Pham-Dinh answered, “100 percent accuracy, and a good wireless Bluetooth microphone.”

Speech recognition packages range in price from about $150 for a basic system without a medical dictionary, using last year’s technology, to more than $1,000 for an advanced solution.

Basic training involves setting up a profile – a five or 10-minute reading of basic text to allow the system to capture a user’s voice pattern – and making corrections to text.

“Fifteen years ago, setting up a profile took about four hours. It’s now down to about five minutes,” said Marriott. “Down the road, we’d like to see it eliminated completely, meaning, you install the software and right out of the box, it’s ready to go.”

What are some of the options for doctors?

For $200, there’s Dragon NaturallySpeaking Preferred Edition. It doesn’t have a medical vocabulary or any custom command features, and it’s not meant for a network environment. However, if none of that matters, it’s a great product.

For $1,150, you can own the new Dragon NaturallySpeaking, Version 8. The ScanSoft product offers 25 percent better accuracy over Version 7, with an overall accuracy of 99 percent, according to the developer.

NaturallySpeaking can also transcribe speech files from a Palm Tungsten, digital recorder or Pocket PC when transferred to a PC.

“It’s more accurate and flexible than previous versions, it’s also got a medical solutions package containing a general medical vocabulary and 14 medical sub-categories,” said Marriott.

In the past, doctors had to purchase a separate vocabulary for their specialty. The cost to upgrade from NaturallySpeaking version 7 to the new version 8 is about $270.

Vianeta Communications, Milpitas, Calif. (www.vianeta.com), offers doctors Harmony, an integrated platform where the files are shareable among its four modules – dictation, speech recognition, transcription, and transcription accounting.

Customers can buy any or all of the modules. If all modules are purchased, there’s a one-time fee of about $5,000 per user plus annual maintenance and support of about $900.

Harmony comes with 22 different medical libraries or language model dictionaries in all, including cardiology, radiology, pathology, and gastroenterology.

An automated report distribution feature provides a web-based interface for physicians to access reports on which they have been ‘carbon copied’ by others. As a result, physicians can access reports regardless of where they are.

Vianeta integrates with the physician’s billing or scheduling system to download patient demographics and billing information.

“The whole cycle of seeing a patient, creating the clinical documentation and billing is optimized,” commented Ralph Aceves, Vianeta Communications’ chief operating officer.

Of the 60,000 physicians using the Harmony platform, about 12,000 use it in their private practices. “Major benefits to users are the optimized libraries, minimal training requirements, and the short time required to get up to speed. Our product leads to a reduction in transcription costs of between 25 and 30 percent. That’s significant.”

For small physician clinics (from solo practices to 10 doctors) Dictaphone (www.dictaphone.com) now offers a web-portal-based speech recognition solution called Physician Direct, using high-speed computer connections to access Dictaphone’s hosted environment. There’s no hardware or software to buy. Users pay a monthly subscription fee of roughly $400 per month, with a two-year contract.

Users get a microphone and 24-7 access to Dictaphone’s data center via high-speed Internet. They have unlimited use each month for their reporting.

Training consists of reading 10 half-page reports into the system, or about 10-15 minutes in total. For users with thick accents or someone who isn’t getting the required accuracy, there’s an optional 2nd phase of another 10 reports.

“Within 15-30 minutes, you get a system that provides nearly 100 percent recognition,” says Ben Hebb, Dictaphone’s area sales manager, based in Mississauga, Ont. “It’s not perfect but it’s highly accurate.” Physicians can check the computer-generated report afterwards, correcting the odd word that didn’t transcribe properly.

That dramatically speeds up the creation of reports, from start to finish. “There’s virtually no turnaround time for reports,” comments David Owen, portal manager for Dictaphone, and the manager in charge of the new Dictaphone application for small physician practices. “Traditionally, when a doctor sends files out for transcription, it takes at least a day and sometimes weeks to receive the final transcription. With voice recognition and self-correction, you eliminate the turnaround time. The report is ready in seconds.”

Owen also asserts that the service can greatly reduce costs for physicians. “For someone who takes a lot of notes,” said Owen, “traditional dictation/transcription is cost-prohibitive.” In the United States, Owen has seen practices in which the physician is paying 10 cents a transcribed line, or up to $3,000 monthly for dictation/transcription services.

By contrast, the Dictaphone web-based offering provides unlimited usage. Moreover, for six users or more in a practice, the cost is discounted by 50 percent.

Unlike other medical speech engines on the market, Dictaphone removes any vocabulary that doesn’t belong in a medical terminology.

“We build from the ground up each individual specialty – radiology, pathology, oncology, general medicine and emergency, about 45 in all, and the user gets access to all of them,” said Hebb. “That’s why it only takes about 15 minutes to train the system.”

He said that Dictaphone also uses other unique technologies, such as guesser files and artificial intelligence, to predict the words that should come next in a sentence. Hebb also believes speech recognition works just as well for people with heavy accents.

“The system gets used to how you say certain words when you read scripts, but it doesn’t stop there. As you do your corrections and use the product, it continues to improve on the accuracy of your profile.”

It’s effective even for people who speak quickly, as long as they enunciate. “It’s the mushing together of words where speech recognition tends to break down,” said Hebb. •

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The joy of sharing

The VIHA leads the way in creating an electronic medical record that can be easily sent back-and-forth from one care-giver to another.
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By Dianne Daniel

Talk about a logjam. Currently, patient information in physician offices is trapped in paper records or incompatible electronic medical record systems – a problem commonly referred to as ‘information silos’. As patients move through the healthcare system, there is no efficient and reliable way to move their healthcare information with them. The data is pretty much stuck in those silos.

Now, however, a solution is in sight. The Vancouver Island Health Authority (VIHA) is taking the lead in setting a standard for the electronic exchange of information between primary caregivers, all in an effort to eliminate duplicate tests, speed referrals and improve accuracy.

Referred to as the electronic medical summary, or e-MS, the B.C.-based project is funded through the province’s portion of a $500 million pot specifically set aside by Health Canada to enhance primary healthcare across the country between April 2002 and March 2006.

Of the $74 million provided to B.C. (based on population), the VIHA project team has received approximately $2.3 million to put towards technical manpower and to facilitate consultation with physicians. A small portion is being used to purchase technology necessary to create a proof of concept.

The e-MS Project aims to provide interoperability for the variety of systems already in use in physician’s offices. It also intends to speed up the adoption of technology by providing efficiencies for computerized practices. To aid in the adoption of its e-MS standard, VIHA is developing a secure web-based application to encourage physicians without access to clinical systems to participate.

“The vision was to get ahead of the problem and develop a means by which all of those different systems that different doctors choose for different reasons could relate to each other,” notes VIHA chief information officer Brian Shorter. “The other main issue is that our information technology strategy strongly emphasizes the need for information to follow a patient through the continuum of services of the health system, instead of forcing the patient to answer the same old questions at each provider.”

One of the first projects to define a core data set for use by primary care givers, the e-MS is based on the clinical document architecture (CDA), an emerging HL7 standard. In addition to defining what data should be collected (such as name, age, prescribed medications, for example), it also provides a standard data format to facilitate the electronic exchange of that information.

To date, the VIHA team has successfully defined a data standard and message broker (or integration engine) to enable referring physicians to electronically communicate patient information despite the fact their clinical systems may vary. Using Web Services as its communications protocol, VIHA has developed a message broker for Microsoft Corp.’s BizTalk 2004 platform but healthcare institutions are also able to use the e-MS standard to build their own integration engines. The technology is both vendor and platform neutral, and is intended to serve as a foundation for broader EHR initiatives nationally.

Overall, the e-MS effort is expected to improve the continuum of care by allowing practitioners to share pertinent data, says Shorter. By replacing a paper-based process with an electronic solution that integrates into physician workflow, it also aims to reduce occurrences of duplicate exams and eliminate costs associated with printing, faxing, mailing, scanning and shredding.

Dr. William Cavers, a family physician in Victoria, B.C., applauds the work under way at the VIHA, despite the fact his clinic has yet to adopt an electronic medical record system. “Although the core subject matter of the e-MS project is as dry as toast it is exciting as hell,” he comments. “If we can get a consensus on the data to contain in a core data set, and the format in which it is transmitted, then we have the potential to make important clinical information available to practitioners – and that’s critical.”

One hurdle to rapid adoption of the e-MS, he adds, is that only 6 to 7 percent of physicians in B.C. are using electronic medical records and automated clinical systems.

George Fettes, a senior business consultant within B.C.’s Ministry of Health Services who works with the Primary Healthcare Branch, agrees, referring to it as “a sort of chicken and egg situation.

“The IT side of the e-MS is just grunt work,” says Fettes. “It’s getting the uptake from the physicians where there’s going to be a struggle.”

More than 30 physicians are signed up for the pilot project, which will initially test the e-MS as a vehicle for information exchange between referring physicians using Wolf Medical Systems’ clinical software.

As Wolf Systems president Dr. Brendan Byrne points out, the notion of a medical summary has always been inherent in EHR-based clinical office systems. What’s new, he says, is that by adhering to the CDA specification set out by the e-MS project team, such systems can share encoded data that will automatically populate systems at the receiving end of a referral – regardless of the vendor involved.

“Part of the problem we’ve seen is there has been no definition of what is a medical summary and what is the core data set,” he says. “The e-MS project tackles that head on and hopefully any project that goes forward in Canada will be referencing this.”

Already, the e-MS project is turning heads south of the border where a similar grass roots initiative – the Continuity of Care Record (CCR) – is also proposing a core data set standard (see sidebar). Meanwhile, the hope in Canada is that the leading-edge efforts of the VIHA team will pay off.

“They’re progressing well; there’s been a lot of good technical work and research done so far,” notes B.C. Health Ministry’s Fettes, adding that people from around the continent have expressed an interest in the e-MS. “We’ll see how things progress once they have a prototype to put in place and try out.”

Future plans call for a province-wide rollout of the e-MS standard, but for now it is slated for implementation in at least two B.C. health authorities by the time the Health Canada funding runs out in 2006. Once the core data set and message broker have proven successful for physician referrals, the next step is to implement the same technology for on-call and emergency events.

As Dr. Byrne points out, when the standard is extended to include emergency room records, patients will notice the benefits as well as physicians. “The regional system knows you sprained your ankle 10 years ago,” he explains. “What it doesn’t know is that your cholesterol is elevated and you were in your doctor’s office two weeks ago with chest pain.”

Two other BC Health Authorities, Interior Health and Vancouver Coastal will be participating in Phase 3 of the project beginning April 1, 2005.

Participation in Phase 3 is not limited to doctors using Wolf Medical Systems’ software. The physicians who have volunteered to participate in the project have brought their EMR vendors with them. In addition to Wolf Medical Systems, Med Access, Clinicare, and Osler have expressed a desire to participate with their physicians in Phase 3.

In addition to those quoted here, we would like to thank Karen Kuhn, Project Manager, Electronic Medical Summary Project (e-MS), Vancouver Island Health Authority, B.C., for her help. •

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