Using voice to create inpatient progress notes: effects on note timeliness, quality, and physician satisfaction.

objectivesWe describe the evaluation of a system to create hospital progress notes using voice and electronic health record integration to determine if note timeliness, quality, and physician satisfaction are improved. MATERIALS AND

methodsWe conducted a randomized controlled trial to measure effects of this new method of writing inpatient progress notes, which evolved over time, on important outcomes.

resultsIntervention subjects created 709 notes and control subjects created 1143 notes. When adjusting for clustering by provider and secular trends, there was no significant difference between the intervention and control groups in the time between when patients were seen on rounds and when progress notes were viewable by others (95% confidence interval -106.9 to 12.2 min). There were no significant differences in physician satisfaction or note quality between intervention and control. DISCUSSION: Though we did not find support for the superiority of this system (Voice-Generated Enhanced Electronic Note System [VGEENS]) for our 3 primary outcomes, if notes are created using voice during or soon after rounds they are available within 10 min. Shortcomings that likely influenced subject satisfaction include the early state of our VGEENS and the short interval for system development before the randomized trial began.

conclusionVGEENS permits voice dictation on rounds to create progress notes and can reduce delay in note availability and may reduce dependence on copy/paste within notes. Timing of dictation determines when notes are available. Capturing notes in near-real-time has potential to apply NLP and decision support sooner than when notes are typed later in the day, and to improve note accuracy.