Using voice to create inpatient progress notes: effects on note timeliness, quality, and physician satisfaction

Area of Science:

• Health Informatics
• Clinical Documentation Improvement

Background:

• Timely and high-quality hospital progress notes are crucial for patient care and communication.
• Current methods of note creation can lead to delays and potential inaccuracies.

Purpose of the Study:

• To evaluate a voice-enabled system integrated with electronic health records for creating hospital progress notes.
• To determine if the system improves note timeliness, quality, and physician satisfaction.

Main Methods:

• A randomized controlled trial was conducted to compare the voice-generated system (Voice-Generated Enhanced Electronic Note System [VGEENS]) with traditional methods.
• Outcomes measured included time to note availability, physician satisfaction, and note quality.

Main Results:

• No significant difference was found in the time between patient rounds and note availability between the VGEENS and control groups.
• Physician satisfaction and note quality also showed no significant differences between the groups.
• Notes created via voice dictation during or soon after rounds were available within 10 minutes.

Conclusions:

• The VGEENS did not demonstrate superiority for the primary outcomes in its current state.
• Voice dictation during rounds can reduce note availability delay and potentially decrease reliance on copy/paste functionalities.
• Near real-time note capture offers potential for earlier NLP and decision support, improving accuracy.