Importance

Speech recognition (SR) is increasingly used directly by clinicians for electronic health record (EHR) documentation. Its usability and effect on quality and efficiency versus other documentation methods remain unclear.

Objective

To study usability and quality of documentation with SR versus typing.

Design

In this controlled observational study, each subject participated in two of five simulated outpatient scenarios. Sessions were recorded with Morae® usability software. Two notes were documented into the EHR per encounter (one dictated, one typed) in randomized order. Participants were interviewed about each method’s perceived advantages and disadvantages. Demographics and documentation habits were collected via survey. Data collection occurred between January 8 and February 8, 2019, and data analysis was conducted from February through September of 2019.

Setting

Brigham and Women’s Hospital, Boston, Massachusetts, USA.

Participants

Ten physicians who had used SR for at least six months.

Main outcomes and measures

Documentation time, word count, vocabulary size, number of errors, number of corrections and quality (clarity, completeness, concision, information sufficiency and prioritization).

Results

Dictated notes were longer than typed notes (320.6 vs. 180.8 words; p = 0.004) with more unique words (170.9 vs. 120.4; p = 0.01). Documentation time was similar between methods, with dictated notes taking slightly less time to complete than typed notes. Typed notes had more uncorrected errors per note than dictated notes (2.9 vs. 1.5), although most were minor misspellings. Dictated notes had a higher mean quality score (7.7 vs. 6.6; p = 0.04), were more complete and included more sufficient information.

Conclusions and relevance

Participants felt that SR saves them time, increases their efficiency and allows them to quickly document more relevant details. Quality analysis supports the perception that SR allows for more detailed notes, but whether dictation is objectively faster than typing remains unclear, and participants described some scenarios where typing is still preferred. Dictation can be effective for creating comprehensive documentation, especially when physicians like and feel comfortable using SR. Research is needed to further improve integration of SR with EHR systems and assess its impact on clinical practice, workflows, provider and patient experience, and costs.

中文翻译：

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医生使用语音识别与输入临床文件：一项对照观察研究。

重要性

语音识别 (SR) 越来越多地被临床医生直接用于电子健康记录 (EHR) 文档。与其他文档方法相比，它的可用性和对质量和效率的影响仍不清楚。

客观的

通过 SR 与打字来研究文档的可用性和质量。

设计

在这项受控观察研究中，每个受试者都参与了五个模拟门诊场景中的两个。使用 Morae® 可用性软件记录会话。每次遇到的 EHR 中都会以随机顺序记录两个笔记（一个口述，一个打字）。参与者接受了关于每种方法感知的优点和缺点的采访。通过调查收集了人口统计资料和记录习惯。数据收集时间为2019年1月8日至2月8日，数据分析时间为2019年2月至9月。

环境

美国马萨诸塞州波士顿布莱根妇女医院。

参与者

使用 SR 至少六个月的十名医生。

主要成果和措施

文档时间、字数、词汇量、错误数、更正数和质量（清晰、完整、简洁、信息充足和优先排序）。

结果

听写的笔记比打字笔记长（320.6 对 180.8 个单词；p = 0.004），具有更多独特的单词（170.9 对 120.4；p = 0.01）。不同方法的文档时间相似，口述笔记比打印笔记花费的时间略少。打字的笔记比听写的笔记有更多的未更正错误（2.9 对 1.5），尽管大多数是轻微的拼写错误。听写的笔记具有更高的平均质量得分（7.7 对 6.6；p = 0.04），更完整并包含更充分的信息。

结论和相关性

参与者认为 SR 可以节省他们的时间，提高他们的效率，并允许他们快速记录更多相关细节。质量分析支持 SR 允许更详细的笔记的看法，但客观上听写是否比打字快仍不清楚，参与者描述了一些仍然首选打字的场景。听写可以有效地创建全面的文档，尤其是当医生喜欢并感觉使用 SR 时。需要进行研究以进一步改进 SR 与 EHR 系统的集成，并评估其对临床实践、工作流程、提供者和患者体验以及成本的影响。