Early adopters have embraced VR as a potential solution and have developed templates that format a report into standardized sections and macros that insert a body of standard text into a report, such as “insert normal chest x-ray” or “insert normal gross appendix.” 3, 4 With dictation costs of approximately 6 to 20 cents per line resulting in annual costs of $5,000 to $15,000 per clinician, organizations are looking for less expensive alternatives. Clinicians and healthcare organizations are looking for solutions to rapidly and cost-effectively generate a legible record. Timely completion and closure of an encounter improves the coding, billing, and payment process. This process usually takes several days to complete, so it is not ideal when rapid access to a record is needed. Reports are incorporated into EHRs by either the clinician or the transcriptionist.

With traditional dictation, the clinician dictates a note or report, which a transcriptionist transcribes and returns for proofreading and approval. 1, 2 The earliest adopters of VR were often radiologists and pathologists because they depended on dictation services that were associated with high costs and delays in report completion. In the same time frame, specific medical vocabularies were created that greatly improved accuracy. Continuous voice recognition became available around 1998 and rapidly became the industry standard. Clinicians who tried VR in the early 1990s used “discrete” voice recognition that required the user to pause after each word. Voice recognition is a relatively new means to enter patient data. Lessons learned can impact future deployment of VR in other military and civilian healthcare facilities. The discontinuation rate of 31 percent was related to location at an outlying clinic and perceptions of inadequacy of training, decreased productivity due to VR inaccuracies, and no improvement in note quality. Forty-four respondents (69 percent) continued to use VR and overall felt that the software was accurate, was faster than typing, improved note quality, and permitted closing a patient encounter the same day.

The variables investigated were user characteristics, training experience, logistics, and VR utility. Seventy-five clinicians volunteered to use VR, and 64 (85 percent) responded to an online questionnaire post implementation to identify variables related to VR continuance or discontinuance. This study evaluated the implementation of voice recognition (VR) for documenting outpatient encounters in the electronic health record (EHR) system at a military hospital and its 12 outlying clinics.

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