Hands down, the one task doctors complain about most is filling out the electronic health record during and after patient visits. It is disruptive and time-consuming, and patients don’t like being talked to over the doctor’s shoulder.
Now, amid an intensifying race to develop voice technologies for health care, a Boston-based company is preparing to release one of the first products designed to fully automate this process, by embedding artificially intelligent software into exam rooms.
Nuance, a maker of speech recognition software, is testing an ambient listening system that, without need for mouse and keyboard, can transcribe a conversation between a doctor and patient and upload key portions of it into a medical record. Executives said they hope to begin selling it next year.
“What we’re really trying to do is have technology wired into the walls,” said Ken Harper, Nuance’s vice president of health care virtual assistants. “All the care team has to do is focus on the patient, listen to the conversation, and take action.”
The product, a rectangular box fitted with 16 microphones and a motion-detection camera, is designed to be mounted on the wall of an exam room to record patient encounters and automatically load key details into corresponding fields within the medical record. If validated, the system would be a significant leap forward in the use of voice technology in clinical care, as it would allow for instantaneous documentation of patient visits and reduce the interference of computers with the doctor-patient relationship.
Nuance’s prototype was a hit at this year’s meeting of the Healthcare Information and Management Systems Society in Orlando, an influential technology conference where long lines of people waited between ropes to get a demonstration of the technology.
“It blew me away,” said Brian Lancaster, chief of information technology at University of Nebraska Medical Center, which is among a handful of U.S. hospitals testing the product. “It was the promise of technology that is truly invisible. It felt like looking into the future.”
Nuance is one of several companies seeking to use voice technology to automate documentation and reduce technology burnout — a problem unlikely to be solved by any one firm or product.
While alluring to doctors, the technology poses thorny questions, including whether patients will be comfortable inviting a third-party company with a camera and microphone into a conversation with their doctor. Perhaps more pressing is the need for Nuance to show that its software is effective outside its demonstration booth and can accurately understand complicated medical conversations in different specialities.
Nuance is planning to introduce the system first in orthopedics, dermatology, podiatry, and other specialities where patient visits tend to be more structured and focused on a predictable set of issues. It is training the system with hundreds of thousands of recordings of patient visits the company is collecting through providers around the country — a trove that will grow bigger over time and help the company refine its product. Such systems do not typically require approvals from government regulators.
Dr. John Halamka, chief information officer of Beth Israel Deaconess Medical Center in Boston, who is not involved in the development or testing of Nuance’s product, said the company is seeking to move beyond the current generation of technologies that enable asynchronous dictation after a patient visit, but not real-time uploading of information into particular parts of the medical record. Electronic records, and the federal regulations that govern them, require doctors to document specific pieces of information on diagnosis, treatment plans, prescriptions, and so forth.
“There are voice recognition products where I can simply dictate, and then a paragraph appears in the medical record,” Halamka said. “That’s fine, but it’s not sufficient. The dream is that the doctor and patient have dialogue, there is no keyboard in the room, and then at the end the clinician reviews the chart and makes any edits.”
“What Nuance has done is probably one of the first production installations of this kind of thing,” Halamka added. Previously, Halamka was an advisor to Suki, a company led by former Google engineers that is also using voice technology to automate documentation of clinical encounters.
Several other companies are working on voice products in medical record keeping, including Microsoft, which last year unveiled an intelligent scribe called EmpowerMD, Sopris Health, Notable, and Seattle-based SayKara. That firm, led by former Amazon engineers, is building a voice assistant also designed to automatically add information from patient visits into the medical record.
Executives at Nuance said they hope the underlying information collected by their product could help advance parallel efforts to use voice technology to improve care. Harper mentioned potential partnerships with companies seeking to use biometric analysis of voice data to predict the onset of depression or Alzheimer’s disease.
“If done right, with the right safeguards, this could give the provider real-time intelligence about what’s really going on” with a patient, Harper said. “You can imagine how health care can be transformed when that [information] is there.”
Perhaps the biggest challenge facing the field is ensuring accuracy, as errors in record keeping can lead to mistakes, or missed opportunities, in the delivery of care. A recent study of a different Nuance voice dictation product, Dragon Medical 360, found that seven in every 100 words contained errors, and many of the errors involved clinical information. Nearly all the errors were caught by follow-up review and editing, but the study authors emphasized that careful supervision remains crucial.
Joseph Petro, chief technology officer at Nuance, said the company is testing and refining its new product, which it refers to as ambient clinical intelligence, to improve accuracy levels and minimize editing time.“It all hinges on what the interface looks like and how easy it is to do the edits,” he said. “This is the real-world part of this problem at this point.”
Nuance executives declined to provide pricing information, but said the system would be sold on a subscription basis, similar to its existing products.
The company’s product is different in form and function than popular consumer devices such as Amazon Echo or Google Home, as it includes a motion-detection camera needed to track the movements of the patient and doctor during the examination as they focus on different areas of the body. The camera does not produce video footage of the sort that could be watched on a smart phone, but only tracks skeletal movements.
Whether use of technology in the exam room will be acceptable to patients remains to be seen. Petro said it is not emerging as a significant roadblock so far, as most patients have not objected its use in testing.
Another key part of the product’s rollout will be informing patients about its use during their visits. Lancaster, the technology chief at University of Nebraska Medical Center, said the hospital is devising a system to inform patients at multiple points in the process of getting care.
“When they check in physically, we will have a script to make sure they didn’t just blindly consent, but really understand that there is technology being used to capture” the encounter, he said.