At Sunnybrook & Women's College Health Sciences Centre (S&W), Toronto, radiologists are teaching a computerized speech-recognition (SR) dictation system to understand what they say. Each radiologist has the ability to develop a dictation profile that teaches the machine to adjust to his or her speech idiosyncrasies. The radiologist can also use predeveloped electronic templates or individually designed macros to speed up the dictation process.

According to the technical administrators overseeing the installation of the TalkStation system from Agfa, the results in the first year at S&W have been remarkable. In some cases, reports that took days to reach clinicians are now available electronically in 5 minutes.

Ian Fulford is S&W's picture archiving and communications system (PACS) administrator. Andrew Volkening is the center's network support analyst and its TalkStation administrator. Between them, Fulford and Volkening constitute the team that has been putting the system into use. Fulford oversees the big picture, making sure that different computer systems integrate functions, while Volkening spends most of his time teaching radiologists how to use the SR system.

According to Fulford, S&W's decision to implement SR followed years of waiting for the software and hardware to reach a level of reliability and affordability that would make purchasing such a system justifiable. As it turned out, that moment came along just in time.

S&W had reached a dictation crisis. "We were facing a facing a severe shortage of transcriptionists with the medical knowledge to do the work," Fulford says. "Our reports were backed up for weeks sometimes. There were tapes misplaced, and a lot of re-reporting. A lot of the problem was troubleshooting: was the problem a misplaced tape, or do we need to go back and re-report the case? There were many problems like that, and those scenarios were unacceptable in terms of level of care."

For radiologists, the backlogs in transcription meant that they had to spend extra time consulting with clinicians, on the phone or in person, so the problem went beyond typing. Since most of S&W's staff transcriptionists doubled as secretaries, temporary transcriptionists had to be hired through outside agencies to keep the reports flowing (albeit slowly). The transcription was all day-shift work; there was nothing resembling 24-hour transcription coverage.

Fulford reports that when it is fully implemented, the system will cost S&W about Can $400,000 (approximately $256,200). Fulford estimates the savings created by using SR will pay for the installation within 2 years. The advantages cannot all be weighed in balance-sheet terms, Fulford notes. S&W radiologists now spend less time in verbal consultation, and S&W has stopped calling temporary transcriptionist agencies. No analysis of saved time for radiologists has been conducted, but Fulford says that none of the radiologists trained to use the SR system would turn back to the old way of dictation. "The best turnaround time for a rush report, before TalkStation, was 24 hours, and it was 48 hours on regular reports. Now, when it's dictated and signed, the report is finished," he says.

S&W is made up of four hospitals (on three Toronto campuses) that merged in 1998. It is a teaching center fully affiliated with the University of Toronto. In the year of the merger, S&W installed an IMPAX® PACS from Agfa. The PACS is linked with fiber-optic cable between the campuses, covering a distance of about 12 km. S&W has 22 staff radiologists and 15 to 20 rotating radiology residents and fellows. The four hospitals perform between 750 and 1,000 individual imaging studies per day, Fulford reports.

S&W has about 90 IMPAX workstations, but only 48 of those workstations are in the radiology departments on the three campuses. The other workstations are clustered in high-volume clinical areas like emergency, trauma, burn, and orthopedic departments. Each radiologist has a workstation in his or her individual office. These are used for reading, but they are also used to train residents. In addition to the office workstations, there are others for use in the radiology departments. Clinicians can use some of these workstations.

When the TalkStation installation has been completed, S&W will have 32 of its radiology workstations integrated for SR transcription, according to Volkening. Those will include the workstation in radiologists' offices and the workstations in the radiology departments that are used for interpretation. There is no need to put SR on the other workstations, since they are not used for reporting.

At present, Volkening adds, there are 15 integrated workstations for radiologists and residents to use to create reports, with 17 more to be installed.

Training

Volkening reports that their physicians are trained over a period of 1 to 2 weeks. Each one has to customize the software to react to his or her voice. In addition, those radiologists willing to take the time to do so can create their own macros to add phrases, word strings, or word blocks to the dictation at the touch of a key or through a spoken command. Volkening says that radiologists who are reluctant to build macros at first usually do so when they see their colleagues working faster than they can. The TalkStation system allows physicians to exchange  and share macros so that best practices can be spread throughout the enterprise. "The system is very flexible," Volkening says. "You can create brief paragraphs that describe the anomaly and then use the macro." The technology also has the ability to create templates with blanks that the radiologist reads into the report. "For example, bone-density tests are a sequence of numerical results, but referring clinicians want to see it nicely laid out in a report," Volkening says. The template is used to create the body of these reports. Only the values need to be dictated.

The transcription system can only work by reacting to sound. If it hears errant sounds, it will try to make words of them, so radiologists have to be careful about background noise. One radiologist had a habit of making scratching background sounds during dictation. Volkening says, "The words the,' and,' and are' were turning up often where they did not belong." The solution was to get this radiologist a headset instead of the customary microphone.

While radiologists are dictating, they have the option of seeing a single line of type at the top of the screen or, with a slight delay, seeing the whole report as it is produced. The reports can be edited and corrected as they are created. All reports can be spell-checked before the system will allow them to be finalized. Volkening reports that many radiologists use both speech and typing as they make a report. Even when they get used to SR, radiologists will spend a little more time completing a report than they did with the old human-transcribed dictation method, Volkening notes, but he estimates that this amounts to only about 5% more time. The time saved by eliminating many verbal consultations and by ending the need to review and correct typed reports is far greater than that, he says. "It takes a little longer to do the initial report, but when you are finished, you can finalize your report instantly. You do not have the clinicians phoning you, and you should never have to go back to that report unless you make an addendum."

S&W's policies in introducing TalkStation have been to proceed at a pace that is easy for each radiologist and not to force anyone to use the system. The use rate is 100% for those who have SR available, and none of those radiologists want to go back to the old way. Volkening says, "Most radiologists find it to be far more complete and accurate reporting because it is more interactive. They are thinking of more things to add to the report because they are reviewing the case as they are completing the report."

The pride of the radiology departments, at this point, is their reporting on musculoskeletal cases. "The radiologists send those reports out every day, before they go home," Volkening says. "They are 100% signed off and available to the clinicians through the PACS, through the radiology information system (RIS), on the World Wide Web, or through the hospital information system (HIS)."

Integration

Ian Fulford's work with Talk Technology has touched all areas of the implementation. A major element of his role has been collaborating with S&W's information technology department and with system vendors to integrate the technology with other databases. Integration with the RIS and the HIS has been essential, but so has making the reports completed using SR available to clinicians on the Internet. S&W is, in fact, one of the first sites where TalkStation has been deployed as an integrated part of the IMPAX PACS. On an ongoing basis, S&W is also a test site for TalkStation upgrades. "We were one of the first sites to run TalkStation on the desktop integrated with IMPAX," Fulford says. "We were one of the only sites to go into production with IMPAX running on the client (workstation) and TalkStation on the same client's hardware. Our IMPAX stations have TalkStation in their hardware."

The integration has been a cooperative effort between S&W's in-house technicians and Agfa technicians, Fulford says. "We have a strong in-house team. We also know that we can rely on our vendors. We can call Agfa, talk to the staff intelligently, and work out a resolution, if there is a problem."

The cooperation between S&W and Agfa since the selection of TalkStation as the center's chosen SR system has broadened. S&W now serves as a prerelease test site for TalkStation, Fulford says. "We run tests in a controlled environment of software released only to a couple of users. We test integration functionality for Agfa in a clinical setting and give it feedback before it releases a product. We do that not for any financial reason, but because it enhances our knowledge of the product. It gives us a chance to clear problems in prerelease. We have probably tested four different versions of software, fixing small glitches. It will be sent back, the codes will be fixed, and we'll test it again." Products being developed do not make their way more quickly into the S&W IMPAX network because of this testing. Only when a general release of a new product has been made does S&W upgrade TalkStation for its radiologists, Fulford reports.

Obstacles

Rarely does a technological installation take place in which no unforeseen difficulties appear. For S&W's SR installation, there have been two barriers. One obstacle was unique to S&W and its legacy equipment; Fulford says that others would not encounter the same problem if they installed TalkStation. It involved old instructions to a mainframe computer that was no longer used. The old software codes had been essentially forgotten, Fulford reports, until they began interfering with billing by radiologists. The old software would not authorize billing for any report completed by a resident, who are not paid for interpretations at S&W. Radiologists have to finalize reports done by residents. When TalkStation was installed, if a resident completed the electronic report, no bill would follow because the resident would be identified as the finalizing radiologist by mistake. This may not seem like a serious obstacle, but it took Fulford, Volkening, and the information-technology staff 9 months to find and correct the problem. During that time, any reports by residents had to be transcribed manually and reviewed and signed by radiologists. "The radiologists could use TalkStation, but the residents could not," Fulford says.

The second barrier involved the way that TalkStation was being used. Radiologists were exiting the SR system too quickly after they had finished a report, and that was throwing IMPAX and TalkStation out of synchronization. A TalkStation user can teach the system new words or change macros at any time, Volkening explains, but those changes are first entered on the workstation computer and then sent to the main server for storage. If a user made changes and then exited too soon, the changes would sometimes fail to get to the main server. The next time that the same radiologist logged in, the updated user profile would not be there. TalkStation would not recognize the updated instructions. S&W's solution was to create multiple backup copies so that a user could recall and replace instructions that had inadvertently been deleted or scrambled. "Anywhere you work, your profile will follow you," Volkening says. "The users would shut down before the profile update went back to the server. Now, we back up data, every week of the month, to different locations. You can always get this backup version of your profile for the past 4 weeks. That was our biggest operational problem."

More than transcription

When a radiologist sits down to report using SR while looking at images on IMPAX, he or she begins by clicking on a dictation icon. That automatically loads in all the patient information from the PACS into TalkStation, Volkening reports. The radiologist then completes and finalizes the dictation and electronically signs the completed report. That signing is an important step (see story, page 13). It constitutes an electronic signature, which has legal implications. It also initiatesat least within the imaging domaina partial electronic medical record in the form of electronically stored images and the electronically stored radiologist's report. Much more is accomplished, however. Interfaces with the RIS and the HIS make the information accessible from those systems. The report is actually lodged on the RIS, and from there, it is available on the Internet to those with the proper clearance. When the radiologist clicks off on a finished report, Volkening adds, he or she is automatically moved to the next set of images or the next patient, whichever is next on the work list.

When clinicians want to see a report, Fulford says, they can go through the HIS and look up the patient from their patient rosters. If the report is available, they know it immediately. Much more often than in the era before SR, the flag used to signal that the radiology report is available is showing.

George W. Wiley is a contributing writer for Decisions in Imaging Economics.