Although speech recognition can speed up documentation process, there may be issues caused by dictation errors. With better approaches, healthcare documentation specialists can avoid these errors.

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How to Eliminate Speech
Recognition Errors
As technology progresses, many providers are relying on speech recognition software
to expedite the process of clinical documentation. However, errors due to the
mistakes of the clinician, poor audio quality, background noise or equipment
malfunction are still common. Errors in dictation can make the patient’s health record
erroneous. A patient’s health record represents the plan of care and actual care and
documents the outcomes. Errors in such documents could reflect in other records
quickly within the EHR system; it can confuse the patient, family, care coordinators
and clinicians and even result in the death of patient. There are methods to eliminate
these errors and prevent them from appearing in the final transcript.
In the case of front-end speech recognition (real-time processing of dictated data), it
is up to the physicians to view the structured text document, identify the errors and
edit the document as it is dictated. This amounts to heavy work for the physicians.
In back-end speech recognition system, a draft of the dictation produced is usually
sent to the Health Information Management (HIM) department along with the voice
file so that medical editors can listen to it, read the draft and correct any mistakes.
Medical editors should consider the following to ensure the accuracy of the data sent
to the EHR.
Proofreading
Proofreading the transcribed documents before routing them to physicians can help
identify errors. Apart from proofreading the entire document, double check vital
information including patient names, medical record numbers and dates. Make sure
that the medical record number matches the relevant patient name. Proofreading
also helps to recognize left-right (for example, left hand mistaken as right hand) and
he-she inconsistencies. Ensure there is no ambiguity in the information presented.
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Thorough Knowledge in Medical Metrics
It is very important for healthcare documentation specialists to have a thorough
knowledge of anatomy and physiology, lab and radiology values and surgical as well
as medical terminology. Trained documentation specialists know lab value
parameters, correct dosages for medications and what makes sense. For example,
they know the meaning of the prefix ‘hypo’ is low and the normal potassium values
generally range between 3.7 and 5.2 mEq/L so that they can correct the errors more
effectively. These professionals should have medical knowledge, especially in the
following areas.
• What drugs work for what indication
• The most appropriate context for common homonyms including
perineal/peroneal/peritoneal, aphagia/aphakia/aphasia, mucous/mucus, and
obfuscation/obstipation
• Common normal lab values for identifying outliers
• Age-relative ailments
Familiarity with medical terminology, disease processes, diagnostics, medications,
anatomy/physiology used for various work types is also vital when editing speech
recognition transcripts. Gaining experience is also another crucial factor for medical
editors. The longer they listen and edit, the more familiar they become with the
terminology to identify correct and incorrect dictation immediately.
Expertise with Tools and Resources
No matter how knowledgeable the medical editors are, questions will arise during the
editing process. The editors should be aware of various tools and resources available
to answer such questions quickly. For example, it is possible to ensure whether the
dosage for a medication is actually available or the dosage sounds right for a
particular situation and patient by checking a drug book. There is a vast spectrum of
tools and resources including expander software, word books, and reliable websites
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among others. Access to sample files and accurate and efficient expander software is
quite useful for editors. Resources like qualified samples i.e., sample dictation after
eliminating protected health information from a specific dictator is extremely useful
for editors to identify the phrases the dictators use frequently while dictating, which
would help them to clarify such phrases in later dictations. Referencing previous
documents of a dictation in question can provide editors with enough context and
hints to solve an issue.
Continuous Training and Education
Healthcare documentation specialists should dedicate themselves to continuous
learning to follow up with any changes in medical terminology or documentation.
Continuous training and education are inevitable to minimize errors. This is because
editing a speech recognition document requires specialized training and a different
set of skills compared to standard transcription. Even experienced editors can benefit
from lifelong learning.
Improved Listening Skills
It’s not just listening to dictation, but how the editors listen that can have a
significant impact on the accuracy and integrity of the transcribed documents.
Listening to the dictation as a whole will help to identify more discrepancies than
listening to fragments. With this, editors can pay particular attention to disease
diagnoses, medications, anatomy/physiology, or diagnostic data that are interrelated
as well as relevant to each other. This approach also allows them to look for
omissions as well as inaccurate information. The editors should not always just hang
on each and every word, but pay heed to what the authors actually meant to say.
This is beyond the usual action of simply listening and transcribing what is said and
let your brain remain on high alert for discrepancies. Editors should improve their
concentration skills, especially when there is a great deal of background noise in the
dictation or within the office environment.
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Interaction with Physicians
Physicians want to get their documentation right the first time as going back and
correcting mistakes demand extra effort and time. This is hectic for medical editors
as well. In order to avoid this double work, it is better to work with physicians from
the beginning itself. For that, the editors should encourage better communication
with the physicians. It is vital to clarify the requirements of physicians before starting
the editing process. They should also provide periodic in-services and/or other kinds
of communication with physicians regarding the dictation standards and protocols.
Flag Doubts
If you are not 100% sure of something and left with no way to clarify it (for
example, proofreading has already been done), then it is a wrong step to make a
guess at what is correct. Medical editors are recommended to flag the document in
such cases and ask either the physician or a QA reviewer for clarification.
Stay Focused
Well-rested healthcare documentation specialists can recognize more discrepancies
and create less transcription errors. Avoid fatigue, stay rested, well hydrated and
take adequate breaks to stay focused while editing or doing QA review.
Hiring medical editors and QA team and giving enough training to them for following
up with all these approaches is really cumbersome and expensive for healthcare
providers. Hiring professional medical transcription services would be a good
option as you can benefit from the service of experienced medical transcriptionists
and benefit from three-level QA process involving proofreaders and editors.
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