Dictation Software to Save Time and Tears

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AUTHOR:
Neeraj Kohli, MD, MBA
Director, New England Center for Urogynecology, Affiliated with Newton-Wellesley Hospital/Brigham and Women’s Hospital, and Assistant Professor, Department of Ob/Gyn, Harvard Medical School, Boston, MA

I graduated high school in 1985 hoping that I would follow in my grandfather's footsteps and become a doctor. Some of the other kids took typing classes in high school, and I thought that was well and good for those joining the secretarial pool or going into journalism. Who could have predicted the value of typing given our use of computers for all future forms of communication and documentation? Fast-forward 35 years and my typing is still at a high school level at best and is far from prime time for the electronic medical record (EMR) keeping requirements of modern day medicine.

Luckily for me, technology has been my savior. For the past 10 years, I have been using Nuance's Dragon NaturallySpeaking™, which is a speech recognition computer program, for EMR and all of my other typing needs. The professional version of NaturallySpeaking is available for less than $100 at your local office supply store and installs easily in a matter of minutes. You need to be patient as the program learns your accent and speech patterns, but recognition and accuracy for the current version is excellent. There is a medical suite version, but I think that the less expensive, consumer version is more than adequate. I currently use the program to dictate into the Harvard hospital’s Longitudinal Medical Record system an ambulatory electronic record system used across Partners Healthcare System. After each patient visit, I return to my desk, turn on the microphone, and dictate the complete and comprehensive note quickly before seeing my next patient. When I finish my last note, I am done for the day—no more long nights to complete notes for patients who were seen in the morning. Better yet, you can create templates for standardized visits, and a simple command, such as "insert pessary check" or "insert normal postoperative visit," will paste the appropriate text in seconds. It is wonderful for routine visits so that I can spend more time with my patients and less time on tedious documentation.

I have found my notes are more complete and natural sounding when I use this marvelous program. It can also integrate with digital recorders or your iPhone if you want to dictate while walking between rooms. It takes a little time to train on the software and establish a routine that works for you and your office, and it is a very worthwhile investment, especially as the requirements for coding documentation continues to increase.

The author reports no relevant financial relationship to Nuance.