Using voice to create hospital progress notes: Description of a mobile application and supporting system integrated with a commercial electronic health record

Abstract

We describe the development and design of a smartphone app-based system to create inpatient progress notes using voice, commercial automatic speech recognition software, with text processing to recognize spoken voice commands and format the note, and integration with a commercial EHR. This new system fits hospital rounding workflow and was used to support a randomized clinical trial testing whether use of voice to create notes improves timeliness of note availability, note quality, and physician satisfaction with the note creation process. The system was used to create 709 notes which were placed in the corresponding patient's EHR record. The median time from pressing the Send button to appearance of the formatted note in the Inbox was 8.8 min. It was generally very reliable, accepted by physician users, and secure. This approach provides an alternative to use of keyboard and templates to create progress notes and may appeal to physicians who prefer voice to typing.

Keywords: Automatic speech recognition; Electronic health records; Hospital care; Physician documentation; Workflow.