For the past six years, Neurology Today has asked neurologists to share their experiences with computer-based tools that aim to improve practice efficiency or quality of care. While some products have passed the test of time and improved, others have been discontinued by vendors or discarded by frustrated users. Two technologies in particular — voice recognition and electronic prescribing — are boasting exciting developments.
San Diego neurologist David A. Stein, MD, who now uses the 9.1 version of Dragon Naturally Speaking (DNS), estimates a 50 percent increase in accuracy from the 5.0 version he began using 6 years ago. The newest version requires little or no training, and users can achieve 98 percent accuracy right out of the box, he said.
The faster he dictates the better DNS performs. Although DNS doesn't make spelling errors, Dr. Stein noted that it does require postproduction editing. For this purpose, he uses a special Microsoft Word macro — a mini-program that executes a series of commands — that automatically amends incorrect phrases. It's also possible to save a copy of the dictation as a sound file for a secretary or transcriptionist to review. (If you're currently using a dictation service, you may unknowingly be doing this already, as many transcriptionists use voice recognition software themselves.)
Vast advances in PC technology — greater memory capacity and new dual core chips — have bolstered the performance of robust applications such as DNS, Dr. Stein said. Although it's best to read a 15-minute training text to build a language model, he noted that DNS Medical already has a built-in comprehensive medical vocabulary that includes medication names. He has trained DNS to convert certain phrases automatically. For example, if he dictates “gdaily,” it changes the words to “daily” in order to meet the standards of the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations).
Dr. Stein can fax reports to referring physicians on the day of patient visit, a service he believes has attracted electrodiagnostic referrals. He also has saved about $10,000 annually from dictation, but pointed out that you lose the benefit of a good medical transcriptionist questioning, “Did you really mean to say that?”
Still, he said, DNS is not for everyone. “It will always be faster to simply pick up a phone or recorder and rattle off a dictation,” said Dr. Stein, who noted that it takes him about five minutes to create a follow-up note compared to the two minutes it used to take him to scribble one out. He advises neurologists who are not technophiles, but nevertheless interested, to contact speech recognition specialists who can make sure that you are set up to use DNS productively.
Accuracy has been a longstanding problem for many neurologists who speak with a foreign accent. Norwalk, CT, neurologist Irina Taraban, MD, has been using DNS for six years and is impressed with the improvements from version 5 to 9. “It takes the same amount of time as dictating,” she said, “and even with minimal training it hardly makes any mistakes, despite my Russian accent.”
Steven Zuckerman, MD, a solo practitioner from Baton Rouge, LA, has been ePrescribing for about seven years. He has tried four systems, and encountered limitations with each one. His first product, iScribe, allowed only printing — not automatic sending — of prescriptions and, ultimately, the vendor went out of business. He went on to use RxNT, which included all the safety functions — dose verification, drug-drug interaction and allergy checking, as well as formulary verification — but was incompatible when he changed to a Treo. When he switched to Bluefish Rx, an application designed for his handheld, he found it useful for sending prescriptions directly, but lacking in comprehensive safety features.
Dr. Zuckerman is now using PocketScript, released by the Zix Corporation in conjunction with Blue Cross. The vendor gave him a Dell Axim Pocket PC and came to set up his office on a secure wireless network. “All the safety features are seamless, but there is clearly an emphasis on prescribing the least expensive medication in a given formulary, adding some unnecessary clicks to the process,” he said. He added that ePrescribing takes more time than handwriting prescriptions, and is tedious to implement at the onset because patient demographics need to be imported from a billing system.
Dr. Zuckerman has hung in there despite all the hassles because he believes that the benefits outweigh the inconveniences. “I can send prescriptions anytime, from anywhere,” he noted, “and it spares my nurse callbacks and all the telephone tag associated with refills.” Likewise, having formulary data at the point of care eliminates disruptive calls from the pharmacy and ensures that patients' medications are ready when they go to pick them up. He also appreciates the drug interaction feature; it recently alerted him that an MAO-B inhibitor was contraindicated when he forgot that his patient was taking a selective serotonin reuptake inhibitor, for example.
FREE SERVICES FOR PHYSICIANS
On January 16, 2007, a coalition of five technology vendors and three major insurers announced their alliance to provide free electronic prescribing services for every physician in the country. The National E-Prescribing Safety Initiative coalition says that it plans to provide secure, Web-based electronic prescribing to any interested physician.
The project is led by Allscripts and Dell as well as other sponsors (including Wolters Kluwer Health, Inc., the publisher of Neurology Today). While many larger groups have already invested in comprehensive information technology systems, the program is targeted to practitioners in smaller practices for whom cost has been the greatest barrier. Best of all, the system is touted to self-populate patient medications from existing pharmacy records, providing doctors with accurate and timely data on what other physicians have prescribed. “I believe that in the not too distant future, all prescriptions will be required to be in an electronic format,” Dr. Zuckerman predicted.
Chicago neurologist Daniel B. Hier, MD, MBA, agrees. When I last interviewed him three years ago, he was using Epocrates along with a simple Word template built into his chart note. He still uses Epocrates as his major drug reference, but subscribes to SigmaPOC for electronic prescribing. He pays a monthly subscription cost of $20 but calculates that for the 250 prescriptions he wrote last year, it was hardly cost effective at $1 each. He intends to switch to the free Allscripts product when it becomes available this month.
Dr. Hier, vice-chair of the AAN Electronic Health Records (EHR) Work Group, said that electronic prescribing works best when it is integrated as part of the EHR. “It automates the documentation process so that all new prescriptions are documented in the EHR, and simplifies the medication reconciliation process by allowing it to integrate with hospital computerized physician order entry (CPOE) as patients move from outpatient to inpatient and back again.”
Technology pundits predict that we'll all be using EHRs within several years. For those who are not yet ready, incremental solutions such as voice recognition and electronic prescribing programs may offer just the right start.