Improving Accuracy of Electronic Notes Using A Faster, Simpler Approach

描述（由申请人提供）：医生病程记录包含对患者护理至关重要的信息，包括病史和体检结果、检查结果的解释、评估和治疗计划。然而，在从纸质病历到电子病历的过渡过程中，许多医生花费了更多的时间来制作病历，这导致了使用复制/粘贴和模板等节省时间的措施，这些措施降低了病历的准确性和质量。这不仅威胁到病历最重要的用途——病人护理——而且威胁到研究、质量改进和支持报销。为了解决这些问题，我们提出了一个具体目标如下的项目：完善和实施一种新的语音生成增强型电子病历系统（VGEENS），将语音识别与自然语言处理以及与电子病历（EMR）的链接集成在一起，以提高病历的准确性和及时性。2. 通过随机试验对VGEENS进行评估，每组30名内科医生评估电子病历的准确性、质量、及时性和用户满意度。干预医生将使用VGEENS，而对照医生将像往常一样继续制作笔记。这种新颖的方法有可能提高记录的准确性，同时减少其他临床医生在电子病历中获得进展记录的延迟。它利用快速改进的语音识别和NLP技术，允许医生使用自然、快速的方法——人类声音——将他们的观察和想法传达到电子病历记录中。

DESCRIPTION (provided by applicant): Physician progress notes contain information essential to patient care, including findings from history and physical exam, interpretation of tests, assessment and treatment plans. However in the transition from paper to electronic physician notes, many physicians spend more time creating them, which has led to the use of time-saving measures such as copy/paste and templates that have degraded note accuracy and quality. This threatens the usefulness of notes not only for their most important use-patient care-but also for research, quality improvement, and in supporting reimbursement. To address these problems, we propose a project with the following specific aims: 1. To refine and implement a new voice-generated enhanced electronic note system (VGEENS) integrating voice recognition with natural language processing and links to the electronic medical record (EMR) to improve note accuracy and timeliness. 2. To evaluate VGEENS using a randomized trial with 30 internal medicine physicians in each arm to assess electronic note accuracy, quality, timeliness, and user satisfaction. Intervention physicians will use VGEENS, while the control physicians will continue with note creation as they normally would. This novel approach has the potential to improve note accuracy while reducing delays in making progress notes in EMRs available to other clinicians. It leverages rapidly improving voice recognition and NLP technologies to permit physicians to use a natural, fast method-human voice-to convey their observation and thoughts into the EMR record.