0
Go with the flow: optimizing voice
recognition to streamline workflow
Je ffre y Che no we th MD
Saint Lo uis VAMC
Kim Wils...
Voice recognition to streamline workflow
• Je ffre y Che no we th
MD
– Saint Lo uis VAMC
• Kim Wilso n MD
– Tucso n VAMC
Voice recognition to streamline workflow
• Driving fo rce s be hind VR
• Pushback – VR
co ntro ve rsy
• VR de ve lo pm e n...
Radiology reporting
• Basics unchang e d in last
ce ntury
• Pro duct no t im ag e s but
re po rt
• Co m m unicatio n to
im...
If goals of reporting are unchanged why
do we need VR now?
Why VR?
• Abse nce o f skille d
transcriptio nists?
• Transcriptio n co st?
– Probably not
Why VR?
• Im pro ve d re po rt
turnaro und tim e
• Fe we r re po rt e rro rs
Why VR?
• Transcriptio n turnaro und
tim e
– Cassette tapes: week – 10
days
– Digital dictation: hours – 3
days
– VR: minu...
Why VR?
• Im pro ve d re po rt
turnaro und tim e 
• Im pro ve d patie nt care
• Make s the Radio lo g y
re po rt re le va...
Why VR?
• Pro ble m s with the traditio nalre po rt
co rre ctio n e diting pro ce ss
– Outside normal Radiologist workflow...
Why VR?
• Erro r pro ne traditio nal
re po rt co rre ctio n – e diting
pro ce ss
– Time lag forgetfulness
• Grammar checki...
Why VR?
• Re po rt co m ple tio n while
im ag e is in fro nt o f
Radio lo g ist
• Im m e diate e rro r
co rre ctio n
• O n...
VR controversy
VR controversy – Radiologist’s view
• Incre ase d dictatio n
tim e
• Incre ase d e rro r rate
vs. g o o d
transcriptio nis...
VR controversy – accuracy rate
• Is 9 5% acce ptable ?
• 9 0 % o f allre po rts have e rro rs prio r to sig n o ff
• 1 0 %...
VR economically justified?
• De cre ase d Radio lo g ist pro ductivity
– 50% longer dictation time
– 24% shorter reports
–...
VR – economically justified?
• Re placing lo we r paid transcriptio nists with hig hly
paid physicians
– Greater Radiologi...
VR – two decades of controversy
• “Has co nside rable po te ntialin the future … at
pre se nt has lim ite d functio n and ...
VR – two decades of controversy
• “Spe e ch re co g nitio n syste m s are use d
to day in m o re than 1 , 0 0 0 radio lo g...
History of VR – a quarter century + of
progress despite persistent controversy
Evolution of Radiology reports
• Pape r re po rts Ele ctro nic re po rts
Transcriptionist model – 1
• Tape s
– Batch transcription
– Batch correction,
signature
Transcriptionist model – 2
• Dig italtranscriptio n
po o l
– In-line transcription
– Batch correction,
signature
Computer data acquisition systems
• Mark-se nse fo rm s
• GE RAPO RT
– AJR 1977; 128: 825
Computer data acquisition systems
• Micro co m pute rs – CLIP Harvard
– Numeric codes for reporting
– Radiology 1979; 133:...
True VR – Kurzweil system 1987
• Re po rte d by se ve ral
Ne w Eng land
ho spitals (including
Bo sto n VAMC)
• 1 , 0 0 0 w...
True VR – Kurzweil system 1987
• Able to dictate a re po rt 8 8 % o f the tim e
– 12% beyond scope of lexicon
• Use o f m ...
True VR – Kurzweil system 1987
• Drawbacks
– Time and attention diverted from film analysis towards
interaction with a mon...
VR – state of the art 1999
– Error rate 30%
– Misrecognition of words
– Increased dictation time
Radio Graphics 1 9 9 9 ; ...
VR – today
• We b archite cture
• Inte g ratio n with PACS
– Improved efficiency
– Decreased errors
• Im pro ve d re co g ...
VR case study: Saint Louis VAMC
VR drivers
• PACS im ple m e ntatio n
– Fewer lost films 
– More reports required
VR drivers
• CPRS
im ple m e ntatio n
• Universal
availability of
patient chart 
• Clinical demand
for faster reports
VR drivers
• Pro ble m o f
pre lim inary re po rts
– Clinical demand
– Error correction
– Legal issues
VR drivers
• Transcriptio n
pro ble m s
– New contractor (low
bidder)
– Cut and paste errors
– Variable
transcriptionist q...
VR drivers
• Turn aro und tim e m andate
– 90% completion in 48 hours  successful
• 95% completion in 48 hours  excellen...
Analysis of options
• Hire m o re
Radio lo g ists
– Full-time
– Part-time
• Retired Radiologists
• Fellows
– Recruiting di...
Analysis of options
• Im pro ve e fficie ncy o f
re po rting cycle
 VR
Proposal for VR system
• Stro ng adm inistratio n suppo rt
• Suppo rt fo r VISN-wide so lutio n
– Some centers opted out
System evaluation
• Radio lo g ist input
• Adm inistratio n
– ADPAC
– PACS coordinator
– IT
• Lite rature re vie w
System evaluation
• Ve ndo r
de m o nstratio ns
– Radiologist trials
• Evaluatio n o f
adm inistrato r
functio ns
Survey existing users
• Mo st site s o nly have
e xpe rie nce with o ne
syste m
• Hard to g e t g o o d
co m pariso ns
• Y...
License issues
• Pe r uniq ue use r
• Pe r wo rkstatio n
• Sim ultane o us use rs
vs. individualuse r
Vendor recommendation and selection
Planning
• Do cum e ntatio n
re vie w
• Site planning
Results
• Re po rt turnaro und 9 0
– 9 5 % within 48
ho urs
• Co st saving s
VR implementation: lessons learned
• Plan, plan, plan
Lessons learned – project team
• Ide ntify m e m be rs
– PACS administrator
– Transcription administrator
– Editors
– IT
–...
Lessons learned – conference calls
• Weekly calls
• Ne e d e ve ryo ne
invo lve d
– IT
– Administrators
– Editors
– Radiol...
Lessons learned – conference calls
• Write q ue stio ns in
advance
• Ke e p m inute s
– Serves as a resource
– Complex pro...
Lessons learned – installation issues
• Adm inistrato r training
critical
• Ge t adm inistrato r
m anuals be fo re
ve ndo ...
Lessons learned – test, test, test
• Te st e ve rything –
do n’t e ve n think o f
im ple m e ntatio n until
this is do ne
...
Lessons learned – test, test, test
• Te st syste m and te st
acco unts
• Re g iste r pro ce dure
nam e s and CPT
co de s
•...
Lessons learned – test, test, test
• Dictate te st re po rts
– Check for proper
upload
– Test addendums and
corrections
– ...
Lessons learned – test, test, test
• Chang e o rde rs
• Minim um o f 1 0 0 te st patie nts
• Te st e ve ry Radio lo g ist
...
Lessons learned – Radiologist champion
• Chang e  re sistance
• Pro m o te syste m ,
co nvince o the rs that
this is way ...
Lessons learned – Radiologist champion
• O ve rco m e o bje ctio ns
– “I’m a physician not a transcriptionist!”
• He lp o ...
Lessons learned – Radiologist training
• Radio lo g ists that have
pro ble m s g e ne rally
did no t g e t g o o d
training
Lessons learned – Radiologist training
• Must have training
sche dule fo r e ve ry
Radio lo g ist
• Eve ryo ne has de dica...
Lessons learned – Radiologist training
• O nce traine d, g o co ld turke y
• Co ntinuing suppo rt
• De aling with no n-nat...
Lessons learned – site trainer training
• Must le arn to train
ne w use rs
• Criticalif re side nts
invo lve r
• Individua...
Lessons learned – continual QC
• Co ntinuale ffo rt and vitalfo r lo ng -te rm
succe ss
• Te st plan
• Te st te le pho ny
...
Lessons learned – continual QC
• Pullre alre po rts and
m o nito r fo r e rro rs
• Inte rve ntio n if ne e de d
• Re train...
Lessons learned – continual QC
• Lo o k in CPRS
– Report text ok
– E-signature ok
– Diagnostic codes
Lessons learned – continual QC
• Mo nito r co ntinually
– Uploads
– Orphan dictations
– Exams without reports
Lessons learned – continual QC
• Ne e d suppo rt co ntract
• Ke e p co ntacts handy
• Kno w who to call
Lessons learned – trouble log
• Take no te s fo r e ve ry
tro uble callto ve ndo r
• Re so urce to fix pro ble m s
o n yo ...
Lessons learned – backup plan
• Backup VR se rve r?
• Utilize ano the r
transcriptio n co ntract?
• O the r m e dicalce nt...
PACS setup and reporting with VR
• Kim Wilso n MD
– Tucso n VAMC
Radiologist workflow: practical points
Goals
• Incre ase dictatio n
e fficie ncy
• Maxim iz e e ye s o n
im ag e
Transcription models – read, edit, done
• Highly recommended
• Minim iz e turnaro und
• Make co rre ctio ns
while im ag e ...
Transcription models – batch correct, sign
• Mo st e fficie nt wo rk
flo w state ?
• Lo ng e r turnaro und
• Erro r co rre...
Transcription models – editor
• Not recommended
• Transfo rm s
transcriptio nist m o de l
co rre ctio nist
• Ine fficie n...
Transcription styles
• Fre e dictatio n
• Te m plate s and
m acro s
Free dictation
• Advantag e
– Keeps eyes on image
• Disadvantag e
– More time with editing
and corrections
Templates – advantages
• Im pro ve d tim e saving s
• Im pro ve d re po rt accuracy
• Co nsiste nt re po rt structure
– Pe...
Templates – disadvantages
• Take s e ye s o f the
im ag e
• May fo rg e t to de le te
no n-re le vant te xt
Templates
• Espe cially use fulfo r
re pe titive bo ile rplate
– Biopsy
– Angiography
• The patient was placed on the
CT t...
Template approaches
• Fe w g e ne ralre po rts
– Fill in the blanks
– Default fill in the
blanks
• Many spe cific re po rt...
Templates– itemized reports
– Lungs: [<normal.>]
– Pleura: [<normal.>]
– Mediastinum [<normal.>]
– Hila: [<normal.>]
– Oth...
Template tricks
• Standardiz e te m plate nam ing co nve ntio n
• Mo dality  bo dy part  side , te chniq ue
Template tricks
• Make te m plate e asy
to chang e o n the fly
• Libe raluse o f
parag raphs
• Case [ ].
• Ultrasound abdo...
Dictation technique
• Fast o k
• Must be cle ar and
distinct
– Think before speaking
– Know what you want
to say
– No fill...
Dictation technique
• Spe ak in phrase s
– Get a flow
– Correct in phrases rather than individual
words
• Use co m ple te ...
Dictation technique
• Co nsiste nt style
• Ke e p re po rts sho rt
• Do n’t num be r ite m s in im pre ssio n
Dictation technique
• Dictate – the n co rre ct
– Keep eyes on image
• Re ad and co rre ct
re po rts care fully
be fo re s...
Microphones
• Pro pe r lo catio n
• He adse ts?
Environment
• No ise co ntro l
• Bullpe n disruptio n
Monitor layout
• O pe n windo w in
adm in m o nito r
– Don’t continually check
transcription
– Dictate then  edit
• Po p-...
Monitor layout
• Se parate m o nito r?
– VR
– CPRS
– Internet window –
Google
– Decision support
software?
– Teaching file...
Training for problem words
• Case num be r  De ce m be r
• Pulm o nary  bo ny
• Adre nal no re nal
Gotchas
• Im pre ssio n:
• Dictate case num be r in e ve ry re po rt
– Troubleshooting
Gotchas
• Ho w re po rts lo o k in VR m ay no t be ho w
re po rt lo o ks in PACS, Vista, o r CPRS
– Line spacing
– New lin...
Residents
• Pre -dictatio n by re side nt
• Make co rre ctio ns and
finaliz e re po rt at tim e o f
che cking
• Easy sig n...
Success rules for VR
• Yo u m ust want syste m to
wo rk
• Training the VR vs. VR
training yo u
• Rule o f thirds
Future development of VR
Improved recognition engines
• Be tte r acce nt
re co g nitio n
• Be tte r re co g nitio n o f
sm allwo rds
Improved integration of PACS, HIS-RIS
• To o e asy to m ark case as re ad whe n no t
• To o e asy to m ark case unre ad wh...
Improved grammar checking
• The re
• The ir
• The y’re
• Two
• To o
• To
• Capitaliz atio n
Structured reporting
• Standard le xico ns
• Unive rsalfram e wo rk
fo r re po rts
– Improve readability
– Minimize style
...
Seamless integration of communication
• Clinicalale rts
• Pag ing fo r critical
finding s
• Fe e dback to
te chno lo g ist...
Ultimate VR goal: universal recognition
Outlook Mailgroup
• VHARadio lo g y Vo ice
Re co g nitio n
105_VI_JC.ppt
105_VI_JC.ppt
105_VI_JC.ppt
105_VI_JC.ppt
105_VI_JC.ppt
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Transcript of "105_VI_JC.ppt"

  1. 1. Go with the flow: optimizing voice recognition to streamline workflow Je ffre y Che no we th MD Saint Lo uis VAMC Kim Wilso n MD Tucso n VAMC
  2. 2. Voice recognition to streamline workflow • Je ffre y Che no we th MD – Saint Lo uis VAMC • Kim Wilso n MD – Tucso n VAMC
  3. 3. Voice recognition to streamline workflow • Driving fo rce s be hind VR • Pushback – VR co ntro ve rsy • VR de ve lo pm e nt • Case study – VR im ple m e ntatio n • PACS se tup and re po rting with VR – Kim Wilson MD • Practicalpo ints fo r im pro ving Radio lo g ist wo rkflo w • Future de ve lo pm e nt o f VR
  4. 4. Radiology reporting • Basics unchang e d in last ce ntury • Pro duct no t im ag e s but re po rt • Co m m unicatio n to im pro ve patie nt care • Pe nultim ate ste p in Radio lo g y pro ce ss • Finalste p -- clinician actio n
  5. 5. If goals of reporting are unchanged why do we need VR now?
  6. 6. Why VR? • Abse nce o f skille d transcriptio nists? • Transcriptio n co st? – Probably not
  7. 7. Why VR? • Im pro ve d re po rt turnaro und tim e • Fe we r re po rt e rro rs
  8. 8. Why VR? • Transcriptio n turnaro und tim e – Cassette tapes: week – 10 days – Digital dictation: hours – 3 days – VR: minutes • Decreases calls for preliminary read • Clinicians expect immediate report availability
  9. 9. Why VR? • Im pro ve d re po rt turnaro und tim e  • Im pro ve d patie nt care • Make s the Radio lo g y re po rt re le vant
  10. 10. Why VR? • Pro ble m s with the traditio nalre po rt co rre ctio n e diting pro ce ss – Outside normal Radiologist workflow – Disruptive – Time consuming
  11. 11. Why VR? • Erro r pro ne traditio nal re po rt co rre ctio n – e diting pro ce ss – Time lag forgetfulness • Grammar checking vs. content errors – Right – left errors – Date errors – DHCP blue screen daze • After 50 + reports, how closely are you reading the report?
  12. 12. Why VR? • Re po rt co m ple tio n while im ag e is in fro nt o f Radio lo g ist • Im m e diate e rro r co rre ctio n • O nce yo u’re do ne , yo u’re do ne • Im m e diate re po rt availability
  13. 13. VR controversy
  14. 14. VR controversy – Radiologist’s view • Incre ase d dictatio n tim e • Incre ase d e rro r rate vs. g o o d transcriptio nist • Re m o ve s fo cus o n im ag e s
  15. 15. VR controversy – accuracy rate • Is 9 5% acce ptable ? • 9 0 % o f allre po rts have e rro rs prio r to sig n o ff • 1 0 % o f re po rts have e rro rs with transcriptio nists – J Digit Imaging Jun 2007
  16. 16. VR economically justified? • De cre ase d Radio lo g ist pro ductivity – 50% longer dictation time – 24% shorter reports – J Digit Imaging Jun 2007
  17. 17. VR – economically justified? • Re placing lo we r paid transcriptio nists with hig hly paid physicians – Greater Radiologist productivity  transcriptionists more cost effective than VR – “… which course of action makes the most economic sense… is not always obvious.” – JACR 2007; 4: 890
  18. 18. VR – two decades of controversy • “Has co nside rable po te ntialin the future … at pre se nt has lim ite d functio n and de finite ly ne e ds m o re te chnicalim pro ve m e nt. ” – Radiology Nov 1988; 169: 580 • “… vo ice re co g nitio n syste m s are curre ntly no t re ady fo r prim e tim e . ” – JACR 2007; 4: 667
  19. 19. VR – two decades of controversy • “Spe e ch re co g nitio n syste m s are use d to day in m o re than 1 , 0 0 0 radio lo g y de partm e nts and are e xpe rie ncing a g ro wth rate typicalo f m o de rn e nabling te chno lo g y. ” – JACR 2007; 4:670
  20. 20. History of VR – a quarter century + of progress despite persistent controversy
  21. 21. Evolution of Radiology reports • Pape r re po rts Ele ctro nic re po rts
  22. 22. Transcriptionist model – 1 • Tape s – Batch transcription – Batch correction, signature
  23. 23. Transcriptionist model – 2 • Dig italtranscriptio n po o l – In-line transcription – Batch correction, signature
  24. 24. Computer data acquisition systems • Mark-se nse fo rm s • GE RAPO RT – AJR 1977; 128: 825
  25. 25. Computer data acquisition systems • Micro co m pute rs – CLIP Harvard – Numeric codes for reporting – Radiology 1979; 133: 349 – Re co g nitio n o f spo ke n num e ric co de s – Radiology 1981; 138: 585
  26. 26. True VR – Kurzweil system 1987 • Re po rte d by se ve ral Ne w Eng land ho spitals (including Bo sto n VAMC) • 1 , 0 0 0 wo rd le xico n • 5 se ctio ns by anato m y o r subspe cialty – Radio lo g y 1 9 8 7 ; 1 6 4: 56 9 .
  27. 27. True VR – Kurzweil system 1987 • Able to dictate a re po rt 8 8 % o f the tim e – 12% beyond scope of lexicon • Use o f m acro s • Dictatio n tim e 20 % lo ng e r
  28. 28. True VR – Kurzweil system 1987 • Drawbacks – Time and attention diverted from film analysis towards interaction with a monitor – Increased dictation time proportional to degree of abnormality on film – Problems with background noise – Problems with repeated interruptions – “Has considerable potential in the future… at present has limited function and definitely needs more technical improvement.” » Radiology Nov 1988; 169: 580
  29. 29. VR – state of the art 1999 – Error rate 30% – Misrecognition of words – Increased dictation time Radio Graphics 1 9 9 9 ; 1 9 : 2.
  30. 30. VR – today • We b archite cture • Inte g ratio n with PACS – Improved efficiency – Decreased errors • Im pro ve d re co g nitio n rate s • De cre ase d turnaro und tim e
  31. 31. VR case study: Saint Louis VAMC
  32. 32. VR drivers • PACS im ple m e ntatio n – Fewer lost films  – More reports required
  33. 33. VR drivers • CPRS im ple m e ntatio n • Universal availability of patient chart  • Clinical demand for faster reports
  34. 34. VR drivers • Pro ble m o f pre lim inary re po rts – Clinical demand – Error correction – Legal issues
  35. 35. VR drivers • Transcriptio n pro ble m s – New contractor (low bidder) – Cut and paste errors – Variable transcriptionist quality
  36. 36. VR drivers • Turn aro und tim e m andate – 90% completion in 48 hours  successful • 95% completion in 48 hours  excellent – Actual far less
  37. 37. Analysis of options • Hire m o re Radio lo g ists – Full-time – Part-time • Retired Radiologists • Fellows – Recruiting difficulties • Pay • Vacation
  38. 38. Analysis of options • Im pro ve e fficie ncy o f re po rting cycle  VR
  39. 39. Proposal for VR system • Stro ng adm inistratio n suppo rt • Suppo rt fo r VISN-wide so lutio n – Some centers opted out
  40. 40. System evaluation • Radio lo g ist input • Adm inistratio n – ADPAC – PACS coordinator – IT • Lite rature re vie w
  41. 41. System evaluation • Ve ndo r de m o nstratio ns – Radiologist trials • Evaluatio n o f adm inistrato r functio ns
  42. 42. Survey existing users • Mo st site s o nly have e xpe rie nce with o ne syste m • Hard to g e t g o o d co m pariso ns • Yo ur m ile ag e m ay vary – Differences in technical, administrative support for system
  43. 43. License issues • Pe r uniq ue use r • Pe r wo rkstatio n • Sim ultane o us use rs vs. individualuse r
  44. 44. Vendor recommendation and selection
  45. 45. Planning • Do cum e ntatio n re vie w • Site planning
  46. 46. Results • Re po rt turnaro und 9 0 – 9 5 % within 48 ho urs • Co st saving s
  47. 47. VR implementation: lessons learned • Plan, plan, plan
  48. 48. Lessons learned – project team • Ide ntify m e m be rs – PACS administrator – Transcription administrator – Editors – IT – Radiologist • De dicatio n e sse ntial • Tim e co nsum ing • Wo rk clo se ly with ve ndo r • Re ad do cum e ntatio n clo se ly
  49. 49. Lessons learned – conference calls • Weekly calls • Ne e d e ve ryo ne invo lve d – IT – Administrators – Editors – Radiologist – Vendor
  50. 50. Lessons learned – conference calls • Write q ue stio ns in advance • Ke e p m inute s – Serves as a resource – Complex project, can’t remember everything – Document to prevent misunderstandings
  51. 51. Lessons learned – installation issues • Adm inistrato r training critical • Ge t adm inistrato r m anuals be fo re ve ndo r re p sho ws up • Write q ue stio ns in advance • Take no te s
  52. 52. Lessons learned – test, test, test • Te st e ve rything – do n’t e ve n think o f im ple m e ntatio n until this is do ne • Ve ndo r supplie d che cklist
  53. 53. Lessons learned – test, test, test • Te st syste m and te st acco unts • Re g iste r pro ce dure nam e s and CPT co de s • Ente r o rde rs into Vista – Check request entry into VR system
  54. 54. Lessons learned – test, test, test • Dictate te st re po rts – Check for proper upload – Test addendums and corrections – Input every type of diagnostic code – Check parent and descendants
  55. 55. Lessons learned – test, test, test • Chang e o rde rs • Minim um o f 1 0 0 te st patie nts • Te st e ve ry Radio lo g ist – Include residents • Te st se nding to e dito r • Te st te le pho ny
  56. 56. Lessons learned – Radiologist champion • Chang e  re sistance • Pro m o te syste m , co nvince o the rs that this is way to g o • Upfro nt buy-in fro m Radio lo g ists • Must se e as im pro ving patie nt care – vs. mandate from administration
  57. 57. Lessons learned – Radiologist champion • O ve rco m e o bje ctio ns – “I’m a physician not a transcriptionist!” • He lp o the rs as o ne pro fe ssio nalto ano the r – Keep people going thru rough spots • Ne e d clo se co m m unicatio n with re m ainde r o f im ple m e ntatio n te am – Get feedback
  58. 58. Lessons learned – Radiologist training • Radio lo g ists that have pro ble m s g e ne rally did no t g e t g o o d training
  59. 59. Lessons learned – Radiologist training • Must have training sche dule fo r e ve ry Radio lo g ist • Eve ryo ne has de dicate d blo cks fo r training , including fo llo w-up – Minimum 4 hours with trainer • Some may need more attention – Follow-up session
  60. 60. Lessons learned – Radiologist training • O nce traine d, g o co ld turke y • Co ntinuing suppo rt • De aling with no n-native Eng lish spe ake rs • De aling with po o r dictatio n style s • Re fre she r training
  61. 61. Lessons learned – site trainer training • Must le arn to train ne w use rs • Criticalif re side nts invo lve r • Individualtraining • Sit in o n use r training se ssio ns
  62. 62. Lessons learned – continual QC • Co ntinuale ffo rt and vitalfo r lo ng -te rm succe ss • Te st plan • Te st te le pho ny • Dum m y o rde rs uplo ading
  63. 63. Lessons learned – continual QC • Pullre alre po rts and m o nito r fo r e rro rs • Inte rve ntio n if ne e de d • Re training o f dictato r • Re build vo ice m o de l
  64. 64. Lessons learned – continual QC • Lo o k in CPRS – Report text ok – E-signature ok – Diagnostic codes
  65. 65. Lessons learned – continual QC • Mo nito r co ntinually – Uploads – Orphan dictations – Exams without reports
  66. 66. Lessons learned – continual QC • Ne e d suppo rt co ntract • Ke e p co ntacts handy • Kno w who to call
  67. 67. Lessons learned – trouble log • Take no te s fo r e ve ry tro uble callto ve ndo r • Re so urce to fix pro ble m s o n yo ur o wn – Record • Day • Ticket # • Who spoke to • Problem • How it was resolved • Note recurring problem
  68. 68. Lessons learned – backup plan • Backup VR se rve r? • Utilize ano the r transcriptio n co ntract? • O the r m e dicalce nte r?
  69. 69. PACS setup and reporting with VR • Kim Wilso n MD – Tucso n VAMC
  70. 70. Radiologist workflow: practical points
  71. 71. Goals • Incre ase dictatio n e fficie ncy • Maxim iz e e ye s o n im ag e
  72. 72. Transcription models – read, edit, done • Highly recommended • Minim iz e turnaro und • Make co rre ctio ns while im ag e is in fro nt o f yo u • O nce it’s g o ne yo u do n’t have to de al with it ag ain
  73. 73. Transcription models – batch correct, sign • Mo st e fficie nt wo rk flo w state ? • Lo ng e r turnaro und • Erro r co rre ctio n m o re difficult – Right – left – Dates
  74. 74. Transcription models – editor • Not recommended • Transfo rm s transcriptio nist m o de l co rre ctio nist • Ine fficie nt, e xpe nsive • Maxim um turnaro und tim e • Must re m e m be r to co rre ct and sig n re po rts • Edito r e rro rs • Whe n is it he lpful? – Non-native English speakers? – Poor dictation technique
  75. 75. Transcription styles • Fre e dictatio n • Te m plate s and m acro s
  76. 76. Free dictation • Advantag e – Keeps eyes on image • Disadvantag e – More time with editing and corrections
  77. 77. Templates – advantages • Im pro ve d tim e saving s • Im pro ve d re po rt accuracy • Co nsiste nt re po rt structure – Personally – Across department – Need agreement among radiologists • Facilitate s structure d re po rting – BIRADS
  78. 78. Templates – disadvantages • Take s e ye s o f the im ag e • May fo rg e t to de le te no n-re le vant te xt
  79. 79. Templates • Espe cially use fulfo r re pe titive bo ile rplate – Biopsy – Angiography • The patient was placed on the CT table in [<supine> ] position. • Initial scans were obtained to localize the [ ]. • An appropriate site at the [ ] was marked. • The patient was prepped and draped in the usual sterile manner. Local anesthesia was achieved with infiltration of 1% Xylocaine.
  80. 80. Template approaches • Fe w g e ne ralre po rts – Fill in the blanks – Default fill in the blanks • Many spe cific re po rts • Case [ ]. [ ] • There is no evidence of fracture, dislocation, or bony destruction. • [<The joint spaces are within the limits of normal.>] • [ < >] • Impression: • [<Negative examination.>]
  81. 81. Templates– itemized reports – Lungs: [<normal.>] – Pleura: [<normal.>] – Mediastinum [<normal.>] – Hila: [<normal.>] – Other: [< >] – Comparison: [<None.>] – Impression: [<normal>]
  82. 82. Template tricks • Standardiz e te m plate nam ing co nve ntio n • Mo dality  bo dy part  side , te chniq ue
  83. 83. Template tricks • Make te m plate e asy to chang e o n the fly • Libe raluse o f parag raphs • Case [ ]. • Ultrasound abdominal aorta. • Real-time ultrasound examination of the abdominal aorta was obtained in transverse and longitudinal projections. • The patient [<does not have an>] abdominal aortic aneurysm. • The abdominal aorta measures [ ] cm in maximal diameter. • [< >] • Impression: • [<The patient does not have an abdominal aortic aneurysm.>]
  84. 84. Dictation technique • Fast o k • Must be cle ar and distinct – Think before speaking – Know what you want to say – No filler sounds
  85. 85. Dictation technique • Spe ak in phrase s – Get a flow – Correct in phrases rather than individual words • Use co m ple te se nte nce s • Use parag raphs libe rally
  86. 86. Dictation technique • Co nsiste nt style • Ke e p re po rts sho rt • Do n’t num be r ite m s in im pre ssio n
  87. 87. Dictation technique • Dictate – the n co rre ct – Keep eyes on image • Re ad and co rre ct re po rts care fully be fo re sig ning
  88. 88. Microphones • Pro pe r lo catio n • He adse ts?
  89. 89. Environment • No ise co ntro l • Bullpe n disruptio n
  90. 90. Monitor layout • O pe n windo w in adm in m o nito r – Don’t continually check transcription – Dictate then  edit • Po p-up in adm in m o nito r
  91. 91. Monitor layout • Se parate m o nito r? – VR – CPRS – Internet window – Google – Decision support software? – Teaching file software?
  92. 92. Training for problem words • Case num be r  De ce m be r • Pulm o nary  bo ny • Adre nal no re nal
  93. 93. Gotchas • Im pre ssio n: • Dictate case num be r in e ve ry re po rt – Troubleshooting
  94. 94. Gotchas • Ho w re po rts lo o k in VR m ay no t be ho w re po rt lo o ks in PACS, Vista, o r CPRS – Line spacing – New lines vs. paragraphs
  95. 95. Residents • Pre -dictatio n by re side nt • Make co rre ctio ns and finaliz e re po rt at tim e o f che cking • Easy sig n-o ff by atte nding • Drawbacks – te m plating – May not learn elements of a good report
  96. 96. Success rules for VR • Yo u m ust want syste m to wo rk • Training the VR vs. VR training yo u • Rule o f thirds
  97. 97. Future development of VR
  98. 98. Improved recognition engines • Be tte r acce nt re co g nitio n • Be tte r re co g nitio n o f sm allwo rds
  99. 99. Improved integration of PACS, HIS-RIS • To o e asy to m ark case as re ad whe n no t • To o e asy to m ark case unre ad whe n is re ad • To o e asy to hang up re po rt – Impression: • To o e asy to fo rg e t to sig n o ff o n re po rt
  100. 100. Improved grammar checking • The re • The ir • The y’re • Two • To o • To • Capitaliz atio n
  101. 101. Structured reporting • Standard le xico ns • Unive rsalfram e wo rk fo r re po rts – Improve readability – Minimize style variation between Radiologists – Data mining • BIRADS
  102. 102. Seamless integration of communication • Clinicalale rts • Pag ing fo r critical finding s • Fe e dback to te chno lo g ist, QA supe rviso r
  103. 103. Ultimate VR goal: universal recognition
  104. 104. Outlook Mailgroup • VHARadio lo g y Vo ice Re co g nitio n
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