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Li Zhou - One of the best experts on this subject based on the ideXlab platform.
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speech recognition for Clinical Documentation from 1990 to 2018 a systematic review
Journal of the American Medical Informatics Association, 2019Co-Authors: Suzanne V Blackley, Li Zhou, Jessica Huynh, Liqin Wang, Zfania Tom KorachAbstract:OBJECTIVE: The study sought to review recent literature regarding use of speech recognition (SR) technology for Clinical Documentation and to understand the impact of SR on document accuracy, provider efficiency, institutional cost, and more. MATERIALS AND METHODS: We searched 10 scientific and medical literature databases to find articles about clinician use of SR for Documentation published between January 1, 1990, and October 15, 2018. We annotated included articles with their research topic(s), medical domain(s), and SR system(s) evaluated and analyzed the results. RESULTS: One hundred twenty-two articles were included. Forty-eight (39.3%) involved the radiology department exclusively and 10 (8.2%) involved emergency medicine; 10 (8.2%) mentioned multiple departments. Forty-eight (39.3%) articles studied productivity; 20 (16.4%) studied the effect of SR on Documentation time, with mixed findings. Decreased turnaround time was reported in all 19 (15.6%) studies in which it was evaluated. Twenty-nine (23.8%) studies conducted error analyses, though various evaluation metrics were used. Reported percentage of documents with errors ranged from 4.8% to 71%; reported word error rates ranged from 7.4% to 38.7%. Seven (5.7%) studies assessed Documentation-associated costs; 5 reported decreases and 2 reported increases. Many studies (44.3%) used products by Nuance Communications. Other vendors included IBM (9.0%) and Philips (6.6%); 7 (5.7%) used self-developed systems. CONCLUSION: Despite widespread use of SR for Clinical Documentation, research on this topic remains largely heterogeneous, often using different evaluation metrics with mixed findings. Further, that SR-assisted Documentation has become increasingly common in Clinical settings beyond radiology warrants further investigation of its use and effectiveness in these settings.
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a study on design and development of enterprise wide concepts for Clinical Documentation templates
American Medical Informatics Association Annual Symposium, 2008Co-Authors: Li Zhou, Tonya Hongsermeier, Rupali Gurjar, Rachel Regier, Stephen J Morgan, Theresa Meyer, Teal Aroy, Debora Scavone Goldman, Blackford MiddletonAbstract:Structured Clinical documents are associated with many potential benefits. Underlying terminologies and structure of information are keys to their successful implementation and use. This paper presents a methodology for design and development of enterprise-wide concepts for Clinical Documentation templates for an ambulatory Electronic Medical Record (EMR) system.
Robert Colebunders - One of the best experts on this subject based on the ideXlab platform.
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Marburg hemorrhagic fever in Durba and Watsa, Democratic Republic of the Congo: Clinical Documentation, features of illness, and treatment.
The Journal of infectious diseases, 2007Co-Authors: Robert Colebunders, Antoine Tshomba, Maria D Van Kerkhove, Daniel G Bausch, Pat Campbell, Modeste Libande, Patricia Pirard, Florimond Tshioko, Simon Mardel, Sabue MulanguAbstract:The objective of the present study was to describe day of onset and duration of symptoms of Marburg hemorrhagic fever (MHF), to summarize the treatments applied, and to assess the quality of Clinical Documentation. Surveillance and Clinical records of 77 patients with MHF cases were reviewed. Initial symptoms included fever, headache, general pain, nausea, vomiting, and anorexia (median day of onset, day 1-2), followed by hemorrhagic manifestations (day 5-8+), and terminal symptoms included confusion, agitation, coma, anuria, and shock. Treatment in isolation wards was acceptable, but the quality of Clinical Documentation was unsatisfactory. Improved Clinical Documentation is necessary for a basic evaluation of supportive treatment.
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marburg hemorrhagic fever in durba and watsa democratic republic of the congo Clinical Documentation features of illness and treatment
The Journal of Infectious Diseases, 2007Co-Authors: Robert Colebunders, Antoine Tshomba, Daniel G Bausch, Modeste Libande, Maria D Van Kerkhove, Patricia Campbell, Patricia PirardAbstract:The objective of the present study was to describe day of onset and duration of symptoms of Marburg hemorrhagic fever (MHF), to summarize the treatments applied, and to assess the quality of Clinical Documentation. Surveillance and Clinical records of 77 patients with MHF cases were reviewed. Initial symptoms included fever, headache, general pain, nausea, vomiting, and anorexia (median day of onset, day 1–2), followed by hemorrhagic manifestations (day 5–8+), and terminal symptoms included confusion, agitation, coma, anuria, and shock. Treatment in isolation wards was acceptable, but the quality of Clinical Documentation was unsatisfactory. Improved Clinical Documentation is necessary for a basic evaluation of supportive treatment. In Durba and Watsa, both situated in Watsa Health Zone, northeastern Democratic Republic of the Congo (DRC), a Marburg hemorrhagic fever (MHF) outbreak occurred between October 1998 and September 2000. A detailed description of the Marburg hemorrhagic fever outbreaks in the Durba area has been published elsewhere [1]. In summary, primary cases were found among gold miners, and secondary cases were found among family members
Louis N Pangaro - One of the best experts on this subject based on the ideXlab platform.
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commentary the rime emr scheme an educational approach to Clinical Documentation in electronic medical records
Academic Medicine, 2011Co-Authors: Mark B. Stephens, Ronald W Gimbel, Louis N PangaroAbstract:Abstract Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and Clinical Documentation skills. EMRs also affect how Clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter–Interpreter–Manager–Educator scheme is one approach to teach and evaluate Clinical Documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.
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Commentary: The RIME/EMR scheme: an educational approach to Clinical Documentation in electronic medical records.
Academic medicine : journal of the Association of American Medical Colleges, 2011Co-Authors: Mark B. Stephens, Ronald W Gimbel, Louis N PangaroAbstract:Abstract Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and Clinical Documentation skills. EMRs also affect how Clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter–Interpreter–Manager–Educator scheme is one approach to teach and evaluate Clinical Documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.
Mark B. Stephens - One of the best experts on this subject based on the ideXlab platform.
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Clinical Documentation in Electronic Medical Records: The Student Perspective
Medical Science Educator, 2011Co-Authors: Mark B. Stephens, Timothy S. Corcoran, Charles MotsingerAbstract:The American Recovery and Reinvestment Act is encouraging widespread implementation and meaningful use of electronic medical records (EMR). Despite this, there is little precedent for teaching medical students the process of Clinical Documentation when using EMR. Following standardized training, we used a focused survey to assess medical student attitudes regarding positive and negative aspects of using an EMR to document Clinical care.
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commentary the rime emr scheme an educational approach to Clinical Documentation in electronic medical records
Academic Medicine, 2011Co-Authors: Mark B. Stephens, Ronald W Gimbel, Louis N PangaroAbstract:Abstract Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and Clinical Documentation skills. EMRs also affect how Clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter–Interpreter–Manager–Educator scheme is one approach to teach and evaluate Clinical Documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.
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Commentary: The RIME/EMR scheme: an educational approach to Clinical Documentation in electronic medical records.
Academic medicine : journal of the Association of American Medical Colleges, 2011Co-Authors: Mark B. Stephens, Ronald W Gimbel, Louis N PangaroAbstract:Abstract Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and Clinical Documentation skills. EMRs also affect how Clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter–Interpreter–Manager–Educator scheme is one approach to teach and evaluate Clinical Documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.
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Teaching principles of practice management and electronic medical record Clinical Documentation to third-year medical students.
The Journal of medical practice management : MPM, 2010Co-Authors: Mark B. Stephens, Pamela M WilliamsAbstract:There is a call for increased implementation of electronic medical records (EMRs) across the United States. Systematic training regarding use of EMRs in medical education is limited. Similarly, medical students receive little training in practice management during their undergraduate years. Using a focused survey and standardized EMR-implementation workshop, we sought to assess medical student attitudes and self-reported skills regarding practice management, coding, and Clinical Documentation. We specifically sought to determine student familiarity and comfort with Clinical Documentation using both handwritten and electronic progress notes and to assess student familiarity with basic coding and productivity measures commonly used in a federal healthcare system.
Enrico Coiera - One of the best experts on this subject based on the ideXlab platform.
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Challenges of developing a digital scribe to reduce Clinical Documentation burden.
NPJ digital medicine, 2019Co-Authors: Juan C. Quiroz, Liliana Laranjo, Ahmet Baki Kocaballi, Shlomo Berkovsky, Dana Rezazadegan, Enrico CoieraAbstract:Clinicians spend a large amount of time on Clinical Documentation of patient encounters, often impacting quality of care and clinician satisfaction, and causing physician burnout. Advances in artificial intelligence (AI) and machine learning (ML) open the possibility of automating Clinical Documentation with digital scribes, using speech recognition to eliminate manual Documentation by clinicians or medical scribes. However, developing a digital scribe is fraught with problems due to the complex nature of Clinical environments and Clinical conversations. This paper identifies and discusses major challenges associated with developing automated speech-based Documentation in Clinical settings: recording high-quality audio, converting audio to transcripts using speech recognition, inducing topic structure from conversation data, extracting medical concepts, generating Clinically meaningful summaries of conversations, and obtaining Clinical data for AI and ML algorithms.
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risks and benefits of speech recognition for Clinical Documentation a systematic review
Journal of the American Medical Informatics Association, 2016Co-Authors: Tobias Hodgson, Enrico CoieraAbstract:Objective To review literature assessing the impact of speech recognition (SR) on Clinical Documentation. Methods Studies published prior to December 2014 reporting Clinical Documentation using SR were identified by searching Scopus, Compendex and Inspect, PubMed, and Google Scholar. Outcome variables analyzed included dictation and editing time, document turnaround time (TAT), SR accuracy, error rates per document, and economic benefit. Twenty-three articles met inclusion criteria from a pool of 441. Results Most studies compared SR to dictation and transcription (DT) in radiology, and heterogeneity across studies was high. Document editing time increased using SR compared to DT in four of six studies (+1876.47% to –16.50%). Dictation time similarly increased in three of five studies (+91.60% to –25.00%). TAT consistently improved using SR compared to DT (16.41% to 82.34%); across all studies the improvement was 0.90% per year. SR accuracy was reported in ten studies (88.90% to 96.00%) and appears to improve 0.03% per year as the technology matured. Mean number of errors per report increased using SR (0.05 to 6.66) compared to DT (0.02 to 0.40). Economic benefits were poorly reported. Conclusions SR is steadily maturing and offers some advantages for Clinical Documentation. However, evidence supporting the use of SR is weak, and further investigation is required to assess the impact of SR on Documentation error types, rates, and Clinical outcomes.