Improving Accuracy of Electronic Notes Using A Faster, Simpler Approach

University Of Washington, Seattle WA

Investigators

Linked publications & trials

Abstract

DESCRIPTION (provided by applicant): Physician progress notes contain information essential to patient care, including findings from history and physical exam, interpretation of tests, assessment and treatment plans. However in the transition from paper to electronic physician notes, many physicians spend more time creating them, which has led to the use of time-saving measures such as copy/paste and templates that have degraded note accuracy and quality. This threatens the usefulness of notes not only for their most important use-patient care-but also for research, quality improvement, and in supporting reimbursement. To address these problems, we propose a project with the following specific aims: 1. To refine and implement a new voice-generated enhanced electronic note system (VGEENS) integrating voice recognition with natural language processing and links to the electronic medical record (EMR) to improve note accuracy and timeliness. 2. To evaluate VGEENS using a randomized trial with 30 internal medicine physicians in each arm to assess electronic note accuracy, quality, timeliness, and user satisfaction. Intervention physicians will use VGEENS, while the control physicians will continue with note creation as they normally would. This novel approach has the potential to improve note accuracy while reducing delays in making progress notes in EMRs available to other clinicians. It leverages rapidly improving voice recognition and NLP technologies to permit physicians to use a natural, fast method-human voice-to convey their observation and thoughts into the EMR record.