Cut Your Transcription Costs

Philip Bachman, MD, is an "early adopter" when it comes to new technology. The infectious disease specialist was among the first physicians, five or six years ago, to try speech recognition software to handle his dictation.

Even though the technology was far from perfect, Bachman reasoned that it would still be better than what he'd been doing: using a telephone-based transcription service for a while, and at another point dictating on tapes that a service would pick up, transcribe, and return a few days later.

Both of those methods were expensive, the Atlanta physician says, and it took too long to get dictation back. Besides, while it was true that the software he bought, Dragon Naturally Speaking, one of the well-known brands in speech recognition, made errors that Bachman would have to correct manually, the human transcriptionists were hardly perfect themselves. Even with experienced medical transcriptionists, Bachman says he'd still have to personally edit the documents -- and often correct mistakes.

"If we'd kept using the service, it would have cost me personally $10,000 to $14,000 a year," he says. "And it takes anywhere from two to three days to get the transcription back. With speech recognition, I dictate it when I see the patient; it's on the chart that day, and I can fax a copy to a referring doctor that day. Also, if I'm out of the office the next day, my partner knows exactly what I was doing."

Speech recognition software is catching on among physicians. It's unclear how many U.S. doctors use the technology, but it's a fast-growing industry, and it appears that most professionals who use it are in healthcare. In recent years, the speech recognition software industry has had $300 million in annual sales, and is growing at a 12 percent annual clip, according to The Gartner Group, an industry research firm. And 60 percent of speech recognition sales are in healthcare.

That data indicate speech recognition products are a rarity among information technology tools: they are available to many industries yet are being adopted most aggressively by often tech-wary physicians.

According to a 2004 survey by the Healthcare Information and Management Systems Society, 28 percent of physicians said they were already using it, and another 52 percent planned to add it in the following two years. That survey may have overrepresented tech-friendly doctors such as Bachman, but other experts suggest that perhaps 25 percent or a third of physicians have begun using the technology.

Working better

It's easy to see why, even among doctors leery of change, speech recognition is popular, says Harry Rhodes, MBA, director of products and services for the American Health Information Management Association (AHIMA). As technology goes it's not very expensive, making it a relatively safe experiment for practices. It has obvious advantages over traditional medical transcription services, which rake in $10 billion annually in North America, according to the Medical Transcription Industry Alliance.

"I can't tell you that speech recognition will necessarily save you time over conventional transcription services, but it will definitely save you money," says Eric Fishman, an orthopedic surgeon who now runs 21st Century Eloquence, a Florida-based reseller of Dragon Naturally Speaking, who services Bachman's system.
And perhaps most important, speech recognition software has increased in accuracy and ease-of-use, and the computer processors needed to run it are getting faster as well.

"The technology is a whole lot better than it was," explains Rhodes. "There are still some issues, but ... it's much better than it was a few years ago. It's kind of like, one day you notice a guy on the street with a cell phone. The next day everyone has a cell phone."

Bachman, who works in a two-physician practice, says he's never regretted making the switch -- especially now that the technology has improved to about 98 percent accuracy. Indeed, to the extent the system makes errors at all, he generally blames himself, saying most of its mistakes occur because he isn't speaking clearly enough.
"It's about as good as I am," he says. "If I'm tired or rushed, it doesn't do as well. If I do it slowly and enunciate, it does quite well."

How it works

Speech recognition software doesn't understand English, per se. Rather, it captures the speaker's utterances and vocal inflections, and places them in context with one another. Then it chooses a word that the speaker appears to be saying from a list of likely suspects. For example, if the speaker says, "Mary went to the store," but mumbles the last word, the software will fill in the blank by choosing from a list of words it knows, based on what it heard the speaker say and what makes sense in context with the rest of the sentence.

That process requires quick "thinking" and a vast vocabulary. The former is now possible thanks to more sophisticated computer processors, and the latter is due to years of software development. "It's still not everything to everyone," says Rosemarie Nelson, a senior consultant for the Medical Group Management Association (MGMA), "but it's gotten more useful for a lot of people."

With the latest versions of speech recognition software, you can dictate directly into a PC, laptop, or into a digital recorder, then transfer the digital recording onto your PC and let the software dictate from the recording. Typically, you'll need a computer with a fast processor such as a Pentium III or equivalent, a good sound card, and 512 megabytes of RAM. Most new computers can meet these requirements, but make sure you know exactly what hardware you need before you buy.

All speech recognition products require you to spend some time training it to understand your vocal inflections before you can use it. With one common product, IBM's ViaVoice, for instance, the user spends more than an hour after initial installation reading prepared text into a headset microphone as the software analyzes his voice. Each physician who plans to use the software will have to spend time training it, and if your physicians like to use more than one computer in the office, it is probably easiest to just install the software to your server rather than loading it onto each of your practice's hard drives.

And because physicians' language is so distinct, it's imperative that the software has a medical vocabulary. Physicians are often tempted to buy generic, out-of-the-box speech recognition software because it's cheaper than more sophisticated versions and thus seems like a good product to experiment with. But consultants such as Nelson advise strongly against this approach; they argue that these basic versions are poorly suited for healthcare. Doctors quickly lose patience and pitch their new purchases in a drawer, Nelson says.

"The software folks have realized that there are different levels of need" for different users, she says. "So if you look at a couple of leading products out there, such as Dragon and ViaVoice -- they both sell different versions, in that there's a small-office or home-office version, there's the professional version, and then there are the medical solutions, which have a more extensive and medical-specific vocabularies."

Nelson calls these medical solutions the "right" products for physicians, though they cost more, "because I think physicians need to recognize that there's a cost of getting in the game. If they want to try speech recognition, it may work very well, but too often, because it's only a trial, physicians invest in the most economical software they can find, and that's almost a pre-determined failure. Because it's not the right tool."

What it costs

The "right" speech recognition tool is not particularly expensive -- at least, not compared to many other healthcare information technology solutions. For example, in November, ScanSoft, the owner of Dragon Naturally Speaking, released its latest medical version of the product, Dragon Naturally Speaking Medical 8, which retails for $1,095. Its standard version of the same product can be had for $99.

That may seem like a big difference, but a $1,000 price tag is not exorbitant when you consider what you're already paying for transcription service, which might run $10,000-$15,000 a year. Even if you don't have the right hardware, it shouldn't cost more than $2,000 to equip yourself with a brand-new computer.

"I tell people, just pretend you're going to school -- you're going to speech recognition school and tuition is $2,000," says Nelson. "It'll cost $1,000 for the software, and maybe another $1,000 on hardware. If it doesn't work, you still have a good new PC, and you never know. It's really a smart thing to try."

Practices should be aware of the pros and cons of speech recognition software, and the efforts required to implement it. The typical 2 percent error rate can be significant, says Rhodes, especially for specialists who do a lot of dictation. (ScanSoft says its latest version of Dragon is down to a 1 percent error rate.)

Physicians who want to get the most of the technology are advised to correct errors manually, using a process that allows the software to learn how to avoid that mistake in the future. That process saves time in the long run but takes more time on the front end.
Another issue to consider is the set-up time, as well as the additional responsibilities of the physician, who must now do his own dictating and editing, which could lead to changes in the physician's workflow habits, says Rhodes.

But those changes need not be drastic. A physician who currently dictates into a tape recorder and then has the recordings transcribed could use a digital recorder and download the recording onto her PC, then run the speech recognition program. But she must still edit the transcription herself.

"Physicians should ask, what's their flow now?" advises Nelson. "When do they dictate now? Where do they do it and how do they do it? Do they step out of the room? Are they using a recording device? A phone? Do they do it from a couple or three workstations? If that's the case, they'll need that many PCs with the software loaded where they do that now. It'll be awfully hard to change those habits, and you might fall behind if you're not using your normal method."

Before you buy

Here are some other tips for getting the most out of speech recognition:

Decide how you want to use the software before you buy. Some practices want to drop transcription altogether. That's certainly possible. "I have a client in Boston where all five doctors use it ... all their consult letters, all their office notes, everything is done in speech recognition," says Nelson. This requires a significant commitment by all the physicians, including a willingness to change some workflow habits and to do all dictating and editing themselves. Other practices choose to use speech recognition less ambitiously -- say, to impress referring doctors by getting notes to them the day the patient is seen, which is impossible with traditional transcription services.

Choose software from a vendor with a good reputation for technical support. Bachman speaks highly of his vendor, 21st Century Eloquence, (www.voicerecognition.com). Ask colleagues for their recommendations. "If you don't know anything about it, you should really buy from a vendor," rather than directly from a Web site or retail store, Bachman says. "There are a lot of little things that you probably need to have someone help you with."

Use macros to make your life easier. Many physicians dictate the same thing over and over again. You can set your speech recognition to recognize verbal macros -- say a few words and it automatically inserts your entire spiel on, say, HIV counseling.

Don't let a pending EMR purchase stop you from trying speech recognition -- or consider combining the two. Many EMR companies, recognizing the value of speech recognition, are now building the software into their systems, but you can integrate your own speech recognition system into your new EMR if you prefer.

Bob Keaveney, an editor for Physicians Practice, last wrote about the Practice of the Year in the November/December 2004 issue. He can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the January 2005 issue of Physicians Practice.