October 2014

Voice Command Technology Enters the OR
By Juliann Schaeffer
For The Record
Vol. 26 No. 10 P. 24

Cutting-edge products provide benefits to physicians and patients alike.

With hospitals large and small struggling to effect positive patient care gains with seemingly fewer resources, it’s no surprise that more health systems are rolling out various technologies in an effort to meet that goal. Speech recognition and voice command are two technologies that seem to be gaining steam lately. While most speech recognition implementations typically involve pure dictation, vendors are finding new places for the technology to shine.

For example, take the operating room (OR). Whether allowing a foot surgeon to instantly capture ankle images during a patient observation or integrating voice command, gestures, and data to help prevent wrong-site surgeries, speech recognition has found a niche in the OR. Early results indicate both physicians and patients already are benefiting from the technology’s novel placement.

drchrono and Google Glass
In June, drchrono, the creator of a free EHR platform that works on iPads and iPhones, and in the cloud, announced it had integrated Google Glass into its EHR technology. The result is a unique health record, “a total mobile wearable medical experience for physicians.”

According to a company press release, the technology is hands free and one step closer to a future where physicians can have their iPad, iPhone, laptop, and Glass “all connected through a mobile EHR platform so they can operate efficiently and spend more one-on-one time with patients instead of processing paperwork.”
Daniel Kivatinos, chief operating officer and cofounder of drchrono, says its medical speech-to-text technology is built to understand advanced terminology.

“Additionally, the technology recognizes unique accents and intonations, making it an adaptive solution suitable for any user,” he says, adding that the tool is capable of “learning” from a physician over time. “The more a physician uses it, the better the technology works. This is significant in that it adapts to physicians with accents or unique ways of speaking.”

The speech-to-text solution is directly integrated into the drchrono platform, giving physicians and medical practitioners the ability to chart and add notes to patient medical records without typing or writing. In the OR, physicians can input notes by voice while performing a surgery, eliminating the need for charting postprocedure. “They can input notes via Google Glass,” Kivatinos says, while noting the possibility of huge efficiency gains.

The technology has the potential to offer two items OR physicians crave: time savings and convenience. “Speech-to-text saves time, as physicians no longer have to set aside time to sit and transcribe their notes,” Kivatinos says. “Charting is hands-free, so physicians can transcribe their notes when and where they like. And physicians can utilize speech-to-text technology for drchrono via their iPhone, iPad, or Google Glass.”

Bill Metaxas, DPM, a foot surgeon with The Foot and Ankle Institute of San Francisco and president of the San Francisco San Mateo Podiatric Medical Association who has been using Google Glass for several months, likes what he’s been seeing thus far.
“Google Glass, combined with drchrono’s EHR platform, has allowed me to instantly capture images while observing a patient, such as for a foot or ankle injury,” he says, adding that the accompanying images and videos add value to a patient’s EHR. “It’s more powerful than a written version.”

According to Metaxas, the integration of drchrono’s EHR and Google Glass has streamlined the medical documentation process during patient visits, saving time and freeing him to provide more patient-focused care. “Doctors can now go hands free with medical records, videos, and pictures and notes, increasing efficiency and improving patient care,” he says. “Integrating Google Glass with the EHR platform has created a total mobile wearable medical experience for my practice.”

While the technology is in its infancy, Metaxas believes it’s here to stay. “I can see Glass becoming an integral part of the norm in a physician’s workflow,” he says. “Today’s modern practices are just starting to integrate applications like Google Glass with EHRs that will make the patients’ records more insightful and useful.”

The Garage’s AiR
Another entry on the OR speech/voice command scene, The Garage developed AiR, a hands-free data interaction tool for health care providers. “Built on the Microsoft Kinect platform, AiR introduces an intuitive patient safety product by integrating voice command, gestures, and data for access during surgery,” says Pranam Ben, founder and CEO of The Garage.

The fully integrated, interactive solution is designed to prevent wrong-site/wrong-side surgery and related surgical errors. Ben believes the tool can help eliminate the horror of patients undergoing surgery on a wrong body part, which is ranked the fourth most common sentinel event after patient suicide, operative and postoperative complications, and medication errors.

Besides a focus on error prevention, the AiR technology is designed to help users increase patient satisfaction, improve OR efficiency, generate better outcomes, and enable better quality and safety practices.

How does AiR attempt to realize those gains? Ben counts several ways, most notably in the areas of patient safety and workflow efficiency but also in its ability to deliver practice management perks. For example, Ben explains how AiR provides scrubbed surgical teams with easy, hands-free voice and gesture access to relevant patient records and surgical details. In addition, the technology sports the ability to zoom in or out of patient images (such as DICOM) without touching a surface. “It also offers seamless integration with back-end EMR/surgery scheduling programs to prepopulate data,” he says. Integrating as a layer over the current EMR system without disrupting it, AiR allows users to access critical surgery and patient information as well as imaging.

Visual surgical site marking using extensive mapping and click-and-touch functionality enhances AiR’s patient safety capabilities. The solution also puts its camera to good use throughout a surgery. “AiR’s camera functionality visually documents and verifies the surgical site and procedure, the electronic ‘timeout’ checklist process, and surgical findings,” Ben says, adding that each of these features helps to ensure surgeries aren’t only performed seamlessly but are actually necessary in the first place.

Administrators can review and audit timeout checklists in real time, tracking quality and compliance across the facility. “AiR provides a much-needed true timeout audit, focusing on the safety of the patient and in turn improving surgical care,” says Jackie Donahue, manager of the Beth Israel Surgical Center in Florida.

AiR, which supports staff communication and practice management, offers an in-surgery dictation feature that can improve the detail and accuracy of documentation. The technology can be prominently displayed in the OR to allow all staff members a view of the patient screen, which can help increase staff accountability and communication. Real-time reports available via a Web-based interface complement compliance reporting and provide operational insights.

“The operating room application for AiR is also only one piece of the product’s suite,” Ben says, noting that the solution also can be used for clinical analysis, interactive training, care interventions, health education, and patient entertainment.
Similar to drchrono’s integration with Google Glass, Ben says AiR integrates into an OR’s EHR system via a flat-screen TV with a Microsoft Kinect camera on the wall. “AiR displays all of the patient’s information for the entire operating team to see during the surgery,” he says.

There are various ways physicians can take advantage of the technology in the OR, but thus far surgeons are mostly using it to verify the correct surgery, site, and patient immediately preceding surgery. “The surgical team can access AiR via the hands-free, voice- and motion-activated Kinect system or by a mouse click/touch interface, if needed,” Ben says. “AiR can also be used to access patient clinical information such as allergies, medications, chronic conditions, etc.”

Ben believes the technology’s chief benefits center around patient safety and OR efficiencies. “Surgical teams can conduct procedures with ease and confidence while health care organizations protect patients, comply with industry regulations, and reduce the potential risks and costs associated with wrong-site/wrong-side surgeries and related surgical never events,” he says.

“It helps our staff adhere to the highest quality and safety practices,” says Ivan Reyes, CEO of the Broward Medical Center in Florida, adding that he has high hopes the technology can boost the practice’s patient satisfaction numbers, which has become an increasingly important aspect of health care practice management.
On the HIM side of the ledger, AiR can have ramifications in terms of documentation and coding. “Automated timeouts and in-surgery dictation allow for a more efficient documentation process in the OR,” Ben says. “And by visual marking, AiR ensures the correct coding for the right procedure at the point of surgery.”

In terms of workflow, he notes the consequences of selecting a similar technology for use in the OR without first determining whether it’s one that fits the care team’s needs and provides minimal interruption.

Privacy Concerns
The technology’s bells and whistles may be alluring, but security must remain top of mind for health care organizations. “Like all other systems used to access patient information, voice command systems also have to be HIPAA compliant,” says Jason Wang, founder and CEO of TrueVault, a provider of health care app data security solutions. “It is no different than using other means of patient health data retrieval.”
“HIPAA regulations, as are related to patient data privacy and access, are applicable to this scenario as well,” says Ben, adding that all patient information in the AiR environment lives in a HIPAA-compliant, cloud-based data center owned and managed by the health care provider.

“The information is protected using industry standard algorithms and protocols such as SHA-1 and salted value hashing,” he says. “In addition, it’s virtually impossible to hack or intercept the data flow as the data is encrypted during transit and storage.”

Wang says voice command systems typically are used to access health data already stored in an EHR. “Therefore, it is important for voice command systems to ensure patient data is properly secured while in flight and any data that is stored locally is erased as quickly as possible,” he says.

According to Kivatinos, all speech-to-text notes and charting for drchronos reside within patient records, which are encrypted and SSL protected. “All drchrono speech-to-text technology is HIPAA compliant in the way that it is integrated into the drchrono system,” he says.

Alhough Metaxas is confident that drchrono’s and Google Glass’s integrated technology securely captures, organizes, and shares patient data and images, he always checks with patients to determine whether they’re comfortable with Google Glass being a part of the encounter.

Accessing patient data using voice command is no more or less secure than retrieving protected health information using a mobile device or a Web application, Wang says. “If the data transfer channel is not properly secured and implemented, patient information can easily be compromised,” he notes.

Wang, who says the correct interpretation of voice commands must be the top priority of systems such as drchrono and AiR, cautions that physicians shouldn’t expect 100% accuracy from any voice recognition technology. To combat the errors—no matter how scarce—that can be inherent in such systems, he recommends a simple solution. “A verification loop should be implemented into all voice command systems to ensure accuracy, much like the requirement for pilots to read back air traffic controller instructions to minimize errors,” Wang says.

The Future
Whether sought for their ability to improve workflow efficiency or their patient safety features, speech recognition and voice command technologies in the OR have the potential to reshape physician behavior. Metaxas recommends physicians get on board with the technology sooner rather than later.

“I feel that the future doctor is one where he or she has an iPad/iPhone and Google Glass all connected through a mobile EHR platform to function more efficiently and spend more time with patients instead of manually processing paperwork,” he says. “It’s so important for physicians to explore and embrace the new health technologies out there that will bring benefits to their patients and practice.”

— Juliann Schaeffer is a freelance writer and editor in Alburtis, Pennsylvania.