Taking advantage of EHR cash incentives written into the 2009 economic Stimulus Package? Radiology departments know what it’s like to transition into the world—and savings—of electronic health record systems with today’s voice recognition technology.

Starting in 2011, hospitals and physicians that purchase approved electronic health record (EHR) systems will see rich cash incentives, thanks to the American Recovery and Reinvestment Act of 2009. With today’s EHR systems able to utilize voice recognition (VR) systems in lieu of transcription departments, administrators may want to consult with their radiology department first about strategies for implementing VR with the least amount of pain—and the maximum amount of gain in efficiency and savings.

Stimulating EHR But Not RIS or PACS

The passing of the 2009 economic Stimulus Plan includes $40,000 to $65,000, phased in over time, for private practice physicians who invest in “approved” EHR systems in 2011; hospitals will receive several million dollars, depending on their size, and payments will be made through higher Medicare and Medicaid reimbursements. That’s the carrot, especially for hospitals and physicians that cover Medicare patients. The stick is that there will be penalties if systems are not adopted by 2016.

The Health Information Technology for Economic and Clinical Health Act (HITECH) will not benefit those hoping for a PACS/RIS subsidy. Why? Perhaps it’s because radiologists are the early adopters of digital information technology with most large hospitals having already invested in PACS. (See “The PACS Picture” editorial online at www.imagingeconomics.com/issues/articles/2009-03_10.asp.)

Consequently, radiology IT departments know the economic and efficiency benefits of going digital, especially when it comes to adapting to voice recognition instead of the old dictate and transcribe model, which wastes thousands of dollars in extra full-time salaries or medical transcription services.

Physicians adapting to new EHR systems will also benefit from VR. However, if radiologists are any indication, they’re not going to like it—at first.

“You walk into a room with radiologists and mention voice recognition, and you better hope they’re not holding clubs in their hand, because they will beat you,” jokes David J. Marichal, RT (R) (CT) (MR) (AART), CIIP, CIO and COO of Radiology and Imaging Specialists, based in Lakeland, Fla. “Doctors are creatures of habit. They don’t like to change the way they do things.”

W. Daryle Heath, BS, RT, director of imaging services at the University of Mississippi Medical Center, Jackson, says that he also found some harsh verbal resistance from radiologists while implementing VR. But he assured his physicians that if they stuck with it, they would see the benefits. “I told them, ‘Look, if you’ll just bear with it and make it through this steep learning curve, you’ll never know how you functioned without this tool after about 45 to 60 days.'”

Both Heath and Marichal said that they were ultimately successful with implementation and physician acceptance, but they had different strategies for getting there.

Assure Them VR Has Greatly Improved

Today’s VR solutions are a huge improvement over previous generations and are only getting better. VR is less dependent on reciting punctuation and training the system to an individual’s voice—although both still help.

The modern VR programs are using what is known as “natural language processing” (NLP), as well as what Pittsburgh-based VR provider M*Modal calls “speech understanding,” which not only accurately transcribes text, but also turns it into relevant reporting data.

Nick van Terheyden, MD, chief medical officer for M*Modal, is passionate about physicians not becoming data entry clerks with RIS/PACS or EHRs. He explained that today’s VR solutions are not just facilitating dictation into transcription, but capturing that text as applicable clinical data for reports, quality control, and practice efficiency.

“What we’re doing is converting that [text] into useful, computer interpretable or semantically interoperable information that can be used by these EHRs without burdening the physicians in the process of creating them,” he said.

Marichal noted, “If [physicians] can talk the way they’ve always talked into their microphones, and yet the information is going to translate and populate in the right places within their electronic medical records, then I think it will be very successful and much easier to transition [into EHRs].”

All modern VR products learn from their mistakes through physicians or medical editors correcting their errors. Some systems, such as M*Modal’s Internet service model, actually learn from everyone’s corrections. For example, if a new medication on the market is corrected by one M*Modal client in the United States, the entire M*Modal service will now be aware of the new medication, thus instantly decreasing the chance that other clients will need to correct the same word.

William Keyes, MD, of Inland Imaging in Spokane, Wash, uses a voice recognition system from MedQuist.

Time and Money Saved

Traditionally, administrators in radiology turn to VR because of the potential savings in transcription costs and report turnaround time. But it’s only when one sees the numbers that physicians become somewhat more motivated.

For the University of Mississippi Medical Center, a teaching institution that has a total of 40 dictating radiologists generating 260,000 reports a year, transcription costs can add up.

Heath said that he saved more than $900,000 annually in transcription services alone. “The cost was a significant issue, but the organization itself was just used to that being the price of doing business. When I came in, I said, no, this is not the price of doing business; this is astronomical what you’re paying.”

While the cost savings was significant, Heath said that the real driving force behind going to VR was report turnaround time. Before VR was implemented, transcriptions were sent to an off-site transcription service that was not only costly, but also slow. “The best turnaround time that this organization was ever able to achieve was about 80% within 24 hours. It was abysmal,” said Heath.

Heath ultimately decided on a VR solution from RadWhere, Burlington, Mass. “Within 3 weeks of using RadWhere and voice recognition, we got the turnaround time up to 96% within 24 hours. Right now, we’ve been on this system for about a year, and now 99.9% of all reports are turned around in 24 hours, and actually 99.6% of all reports are turned around within 12 hours.”

Heath added, “It’s really had a huge impact on the teaching organization and the expectation of the other services and how they feel that radiology is an integral part of the health care team now.”

Marichal runs a smaller radiology group and radiology center, covering four hospitals and a multicenter clinic, generating 150,000 imaging studies a year.

Although it’s been less than a year since VR implementation, Marichal estimated that he would see a savings of $100,000 due to cutting his in-house transcription personnel from seven transcriptionists to three full-time and one half-time employees. He believes there will be even more savings once he factors in maintaining and providing equipment and remote connectivity for the transcriptionists, plus all of the costs associated with employee benefits.

“For us, to have a reduction of over $100,000, it’s a huge financial benefit. Everybody’s looking to cut their costs,” he said.

As with Heath, Marichal also saw report turnaround time improve—though the department was already very good. It is now an hour or less on routine exams and 15 minutes on stats—all using the back end medical editor system.

Heath sees specialty groups benefiting greatly from an EHR with a VR system, believing they could increase their referral business. He said, “If they can see a patient in clinic, dictate that report while that patient is checking out or leaving, and before that patient gets home, the physician who referred that patient has a report in front of them that has been automatically e-mailed to them? That’s a no-brainer right there.”

And for those physicians who say that they are not data entry clerks, Heath responded that 9 or 10 years ago, radiologists felt the same way. “For a while, that was an argument that kind of held up. Until the group down the street got voice recognition, implemented it, and started seeing their business move over to someplace that could provide them a report in hours instead of days.”

Self-Edit or Medical Editor?

There are two schools of thought when it comes to using VR in any kind of RIS/PACS or EHR, the front-end system and the back-end/medical editor system.

In the front-end system, physicians dictate directly into a computer or handheld device, immediately self-edit inside the report, and then sign off on the findings and send it to the referring doctor. There are no medical editors at all.

In the back-end medical editor system, the physician dictates as he always did, while the VR system populates the correct categories in the template. A medical editor then reviews the initial report, corrects any errors, and sends it back to the physician for final approval. As far as the physician is concerned, he is dictating the same as always, but the transcriptionist/medical editor’s workload is significantly decreased.

Heath chose the front-end, self-edit approach because he had the backing of the university behind him, despite the protests of physicians.

For Marichal’s private practice group, he tried the self-edit model, but finally had to settle for the back-end system. He explained, “It’s one thing for a hospital to force it and to try to do VR, but these are the guys who own the practice. They’re not going to do anything they don’t want to do, essentially.” He noted, however, that if the Report screen does not show a lot of red marks, some physicians will self-edit and sign off immediately on the report.

Whether physicians chose the front-end or back-end model, both systems will increase efficiency and accuracy: Prepopulated data, such as patient history and past exams and insurance information, will be ready to be reviewed by the physician. There are no more struggles to read the scrawls of handwriting, or find a stray lab report sheet. As with radiologists, EHRs have the potential to replace file rooms or decrease them in size. Even better, there will be little chance of losing a folder. All systems have some sort of backup data system.

The Learning Curve

Most physicians agree that EHRs, just as PACS and RIS, will eventually improve patient care. The real objection is learning the new system and making it work.

There are also two physician-training philosophies when it comes to VR: There are drop-dead dates, or the more gentle approach.

For Heath, the task was to train all 40 students and radiologists with a strict drop-dead date for full implementation. He said, “We had blitz-type training that went on with the radiologists, whereby with your initial training session, they would sit one-on-one with a trainer for an hour, or an hour and a half, then they would have a follow-up training session either 3 or 4 days later.”

There were several more opportunities for training, including more one-on-one sessions. Heath said Nuance strategically planned out the training sessions with all 40 users to meet the deadline.

When it came to the go-live date, things went better than expected. “There was a significant learning curve, but it wasn’t nearly as bad as I thought it was going to be, as far as the backup of reports,” Heath said.

Marichal also said that the learning process went well for his radiologists, but he points out that he did not have any hard and fast drop-dead dates, which was less important for the back-end medical editor system.

“A lot of people asked me, how did you get your doctors to do this? I say that most of them don’t even realize that they’re doing it, because it’s so much on the back end. It’s not intrusive. It’s not this rub to the workflow, and I think that’s the key,” said Marichal.

Marichal said it is the unobtrusiveness that was the key to the VR being successfully implemented “The radiologists didn’t really see any difference in how they were doing things. They have the flexibility. … When the text comes up, they can send it to the medical editor, they can self-edit real quickly, or they park it in a draft status if they want to come back to it later because they didn’t like something.”

The EHR-VR Road Ahead

The government is still assessing what will be “approved” systems for the Stimulus incentives, and it remains to be seen whether VR will be recommended as part of a system.

With the advent of more thin client/Web-based models in RIS/PACS, EHR software will most likely head down the same road.

As to physicians accepting VR as an essential part of modern medical practice, Marichal points to his younger brother, who is starting his fellowship in interventional radiology.

“He’s known nothing but PACS and VR,” said Marichal. “That’s how he was trained. But not everybody is within that environment, and if you’re not in that environment and you weren’t trained that way, you have to ease yourself into it.”


Tor Valenza is a staff writer for Axis Imaging News.