Completeness of the electronic medical record with the implementation of speech recognition technology

Abstract

The advent of the electronic medical record (EMR) has transformed the process of clinical documentation. When combined with the speech recognition technology (SRT), EMR completeness has increased over methodologies without this technology. This research examined chart audit completion scores of physicians and scribes working within four Northeastern Ohio Emergency Services departments. SPSS® Statistics were used to perform a Repeated Measure Analysis using paired-samples t tests calculated to compare mean completion scores one month prior versus six months after SRT implementation. The mean completion score of pre-SRT implementation with and without the assistance of scribes was 5.5 ( sd = .8) and the mean completion score of post-SRT implementation without the assistance of scribes was 6.0 (sd = .9) indicating a significant increase from pre-SRT versus post-SRT implementation (t(17) = -3.9, p < 0.5). The mean completion score of pre-SRT implementation without the assistance of scribes was 5.0 (sd = 1.1) and the mean completion score of post-SRT implementation without the assistance of scribes was 6.0 (sd = .9) also indicating a significant increase from pre-SRT versus post-SRT implementation (t(17) = -4.7, p < 0.5). These analyses validated the strong statistical probability that the completeness scores of physicians utilizing SRT will exceed the total completeness scores of physicians and scribes not using this technology. Subsequently, the null hypotheses were rejected in support of the alternative hypotheses, which concluded: 1) The completeness of the EMR will at least remain the same or improve with the implementation of SRT. 2) The completeness of the EMR will at least remain the same or improve when speech recognition technology is used without scribe utilization.