Improving Accuracy of Electronic Notes Using a Faster, Simpler Approach

Physician progress notes are an important record for clinical care and communication with care team members and patients. Moving from paper to electronic physician documentation improved the availability of notes in electronic health records (EHRs), but electronic notes are often criticized for poor readability, overuse of copy and paste, and increased length due to importing data stored in other parts of the EHR. Most concerning is the perception that electronic notes may not accurately reflect the patient encounter, threatening the quality of patient care and clinical research.

This project developed, implemented, and evaluated a voice-generated enhanced electronic note system (VGEENS) that was designed to address the problems of electronic progress notes. VGEENS integrates voice recognition and transcription with natural language processing (NLP) to create inpatient progress notes. The system was designed to match the workflow of physicians when doing inpatient rounds. The goal of VGEENS was to improve accuracy and timely availability of inpatient progress notes.

The specific aims of this project are as follows:

• Refine and implement VGEENS and integrate it with voice recognition, NLP, and links to the EHR to improve note accuracy and timeliness.
• Evaluate VGEENS using a randomized controlled trial (RCT) to assess electronic note accuracy, quality, timeliness, and user satisfaction.

The RCT assigned physicians in the intervention group to VGEENS and the control group to the usual practice of typing notes using a locally developed template. Early results suggest that VGEENS was associated with longer length of time for progress notes to become available in the EHR compared to the usual method. This result was unexpected and the study team hypothesized that physicians did not dictate their notes at the bedside, or immediately after leaving the bedside, as had been anticipated, contributing to the time increase. Additionally, physicians were averse to creating notes using VGEENS, citing prior negative experiences with dictation and reluctance to learn a new skill during their busy clinical rounds.

Technical enhancements to VGEENS are underway. After a detailed outcomes analysis is completed, additional enhancements may be planned. The goal of the VGEENS refinements is to improve the speed and accuracy of creating a note using VGEENS.