Dictaphone introduces software to overcome barriers in clinical documentation

mdEssential combines  voice dictation, speech recognition, and natural language processing

Don Fallati, Dictaphone senior vice president, marketing & strategic planning, has noted that discussions of the Electronic Medical Record (EMR) often miss the importance of extracting information rather than just saving a digital version of unstructured text. (See company profile, SRU, July 2005, p. 3.) In late July, Dictaphone Corporation addressed this problem in part with the introduction of mdEssential, a software solution designed to automate the clinical documentation process in the clinic and physician group practice markets. mdEssential combines Dictaphone’s voice dictation, speech recognition, and natural language processing (NLP) technologies. Dictaphone has made significant investments over the past several years to develop its own natural language processing technology. Dictaphone also reported growth in its iChart web-based medical dictation service (p. 11).

The mdEssential software is intended to reduce documentation time and transcription costs by removing manual processes from the traditional dictation/transcription process, while meeting the essential data capture requirements of the EMR. The solution is designed to allow physicians to continue to work in a comfortable environment consistent with their current habits. The mdEssential package serves as a cost-effective alternative to EMR systems for clinics and practices that are not yet ready to invest the significant time and resources required to re-tool their operations around a traditional EMR system. Dictaphone’s NLP software can analyze text documents and extract important medical facts such as allergies, medications, diagnoses, and procedures, creating structured data from narrative patient reports rather than forcing doctors to enter such data manually.

“After so many years of availability, the low adoption rate of EMRs suggests that physicians feel something is missing from this class of software,” said Fallati. “We believe that mdEssential is an ideal middle ground between free-form dictation and structured documentation providing data capture and reporting at an affordable cost, with little change required to the physician’s current habits. This approach permits retention of narrative detail while generating the most important structured data for the EMR database.”

mdEssential uses NLP technology to analyze the text of dictated records (including historic records), and then populates patients’ medical records with the data. Dr. Theodore Them, Section Chief Occupational Medicine at Guthrie Healthcare System describes the process: “With NLP, I can sit at a screen and access with one-click a comprehensive past medical history for my patients...seeing in one place complete and up-to-date information, including a summary of past surgeries, medications, adverse reactions, which physicians have been seen, as well as the most recent diagnostic codes.”

With traditional EMRs, caregivers are typically required to shift to a “point-and-click” or keyboard data-entry method to complete their clinical notes. Dictaphone’s mdEssential retains voice input, a popular mode with physicians, and adds speech recognition to create speedier turnaround times for documents. In addition, caregivers can use voice-driven templates and standard text blocks to further shorten documentation time.

A query tool permits searches of the data to find specific information, including immediate access to the corresponding reference in the source document. By extracting key information from dictation, mdEssential also addresses the problem of incomplete patient information databases in EMRs.

Dictaphone has packaged the mdEssential offering to be flexible and cost effective for the clinic and group practice segment. mdEssential is available immediately direct from Dictaphone or from one of the company’s authorized resellers.