This Will Change Your (Medical Professional) Life
Started using M*Modal this past year and it has been a game-changer for me. Anyone else using it?
Started using M*Modal this past year and it has been a game-changer for me. Anyone else using it?
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Do you use speech recognition software?
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We have M-Modal at my HCA sites, and DragonSpeak at my non-HCA sites.
Not having this isn't an option for me anymore.
Not having this isn't an option for me anymore.
This 100%
I can work without scribes, but at this point the thought of typing up a HPI is a total dealbreaker
I can give a command to Cerner in two keystrokes, and it gets it right, 100% of the time.
We have Dragon, and have had it since we installed our EMR (Cerner). Turned down many jobs that refused to get speech recognition. It seems standard in functional hospitals, and I would never work without it.
I am floored that some places refuse to invest in it.
I am floored that some places refuse to invest in it.
We have Dragon, and our IT guy says it's Medical Dragon, and we pay handily for it. I don't believe him. Just two right off the top of my head: Xarelto is "zarella toe", and edematous is "edema toes" (but it does get "rivaroxaban"). I don't recall others, because they are so nonsensical. Also, our version has an annoying function where articles and helper verbs are not transcribed. The most grating is "Patient be discharged". It sounds like AAVE, and that is not how I speak. I can understand if the leading "The" is dropped, if that is my fault for talking before it is engaged, but there is NO reason it misses "will". However, even when I do not release the button, the "The" is dropped, after dictating multiple sentences in a row. And, sometimes, I have to over-enunciate, like "Oh, excuse me your honor, these two yooooottthhhesss". I am NOT saying "dese two yutes".
I hate Dragon for the reasons above, too many errors. I spend as much time correcting as I do dictating. Never used M Modal. Heard it was much better.
Sent from my Pixel 3 XL using SDN mobile
Sent from my Pixel 3 XL using SDN mobile
My favorite dragonism ever was the day it spit out "leuko-piña."
Really Dragon? Really?
There are different versions of M-Modal out there - one system I work with is pretty good. The other has this ANnoying habit of randomly capitalizing THe first two letters of words. ITs so annoying...
Really Dragon? Really?
There are different versions of M-Modal out there - one system I work with is pretty good. The other has this ANnoying habit of randomly capitalizing THe first two letters of words. ITs so annoying...
This happened to us after we went from "Dragon" to "Dragon Medical".
It also had the unfortunate effect of not being able to execute any commands such as "copy that", "paste that", "strike that", etc.
Dragon Medical was a hard step-down from just plain-ol' dragon.
I have mine trained that it doesn't miss a beat.
Zosyn and Xarelto aren't a problem, but usage of "to", "too", and "two" is.
Be happy that you catch these errors; it means that you actually read your chart and give a damn.
So many MLPs just take it all for granted that its getting it right, and when I catch the errors, they go thru "concern", "panic", "doom", "denial", "accusation", and whatever.
Agreed. I'm a pretty fast typist, and I've found that typing is actually quicker than using Dragon, and having to go back and correct all the errors. One place I worked used to return every chart to me for "correction" when Dragon would put "he" instead of "she" in the text. That's what made me give up.
We use M-Modal's Fluency direct. My macros are able to get through all of the documentation needed for a level 5 chart with MDM and discharge instructions in about 2 minutes. Sadly I can chart faster with dictation than I can correct a scribe's note.
Object-oriented grammar fixes all of this.
Before everyone hates me, my aunt was an English professor.
"Patient states x-y-and-z."
"Patient adds xx, yy, and not zz."
"Patient denies aaa-bbb and ccc."
She would probably shake with rage after reading some of your posts....
Touche', old boy. Well played.
In truth, I often think about her when I do something super-stylized, such as the 4-chan thing.
Regarding the topic at hand, I think it matters very much which "version" or "build" of the software that you're using.
I remember saying those exact same words to dchristismi "I can type faster than I can correct all those errors." when we worked together.
It held true when we worked together in central florida. Those charts were an abortion. Thank Christ we had sovereign immunity.
Several years later, my present dragon setup has improved so radically that I won't use anything else.
We have dragon and scribes. We just recently started being "penalized" for use of scribes with their hourly salary coming out of our paycheck. Some of us have decided not to use them but most of us have become spoiled and continue to use them. I can probably see 2-3 more patients and def decreases stress.
I never use dragon with scribes. It's always faster for me to type. If I'm having to do all my charts though, I've started using Dragon for HPI. I like using the mobile app and standing outside the door and dictating HPI/EKGs and going room to room, then when I get back to computer, I can just dump it in the note(s). For the most part though, I can type faster than I can dictate. That's the only time I really use it.
I never use dragon with scribes. It's always faster for me to type. If I'm having to do all my charts though, I've started using Dragon for HPI. I like using the mobile app and standing outside the door and dictating HPI/EKGs and going room to room, then when I get back to computer, I can just dump it in the note(s). For the most part though, I can type faster than I can dictate. That's the only time I really use it.
Groove, what type of setup do you have to dictate on your phone and dumping it into a note?
Most proficient typers type about 80-105 wpm. Dictation can usually get about 150 wpm. There is additional time needed to proofread a dictation though. However, for me, it's easier to tell a story than to type a story. Plus my fingers feel less tired at the end of a shift. Maybe it's completely in my head, but my shifts seem to go easier dictating than typing or clickboxing my notes.
With DMPE and all my macroblocks for physical exams/review of systems, I can usually dictate a thorough charge in about 90 seconds to 2 minutes depending on complexity (this including detailed MDM). You can purchase templates that will allow you to do charts pretty fast, but I have designed my own dictation template in Epic and macroblocks.
Most proficient typers type about 80-105 wpm. Dictation can usually get about 150 wpm. There is additional time needed to proofread a dictation though. However, for me, it's easier to tell a story than to type a story. Plus my fingers feel less tired at the end of a shift. Maybe it's completely in my head, but my shifts seem to go easier dictating than typing or clickboxing my notes.
With DMPE and all my macroblocks for physical exams/review of systems, I can usually dictate a thorough charge in about 90 seconds to 2 minutes depending on complexity (this including detailed MDM). You can purchase templates that will allow you to do charts pretty fast, but I have designed my own dictation template in Epic and macroblocks.
"Penalized" for using a scribe? K, I'm gonna "penalize" you by seeing 1 less patient an hour.
Having used both Dragon Medical and M*Modal fluency direct I can tell you that the M*Modal speech recognition software is VASTLY superior to Dragon. I'm not sure what kind of black magic they use to do this but at the end of my shifts when I'm tired and I start mumbling into the microphone it can still understand what I'm saying! With Dragon I found that I was constantly having to go back to correct all of the mistakes it was making. M*Modal also has an app you can use to dictate from your phone. It doesn't work as reliably as a dedicated microphone but it's a nice option to have.
One place I work charges $20/hour for the scribes. For $200/shift I will do my own charts. Scribes are only useful if you are in a place where you could theoretically see an unlimited amount of patients, so that adding the scribes increases productivity. Right now I am in a place which highly structures when, and what types of patients I can see, so that usually there's a definite maximum to what I can pick up. Scribes are of no value in that environment.
I did use scribes at my last job in Texas (which I just quit after 4 years) because they spoke Spanish and could translate for me which made my job vastly easier.
Wow.
I remember a thread that I wrote so long ago entitled "Do Your Scribes Suck?"
Seems that, across the board... scribes suck.
I remember a thread that I wrote so long ago entitled "Do Your Scribes Suck?"
Seems that, across the board... scribes suck.
I have been recently thinking about picking up dictation. I pay about $1,500 - 2,000/month for scribes out of my own paycheck. I work about 15 shifts/month.
I have serious doubts whether I will be able to get our hospital to install dictation software on all the potential computers that I use during a shift. That means that I would have to
- purchase a laptop for work
- purchase dictation software and install it on the laptop i just bought
- use that laptop at work.
So how much would all that be? Can you use something dictation software on Chrome, a cheap laptop? I would love to be able to try all this stuff out for a month to see how well it would work. If I like it I would buy everything, if not I would return it and go back to scribes. I could potentially save myself, on order of, about $20,000 / year.
I too am a very fast typist. I usually write my MDM's in a Google Doc that I share with my scribe. I use Cerner. I find that overall scribes increase my productivity and pay for themselves.
Problem too is when I dictate my MDMs to scribes, I'm often stopping myself, editing what I say, telling them go fix this and that, erase this, repeat that...and overall making a mess of it. My typing tutor software app says I can type about 337 characters/minute with 96% accuracy. ( I just did it a second time, 425 chars/min with 98% accuracy.) Hmm....
can you put any of this M-Modal or Dragon software stuff on your iPhone and somehow dictate into your phone?
Maybe I could open a google doc on my phone, dictate onto that and then the scribe can put it in the chart.
Just thinking out loud.
Maybe I could open a google doc on my phone, dictate onto that and then the scribe can put it in the chart.
Just thinking out loud.
How are you paid? Employed?
Sorry for the very long post, but it contains a lot of useful information that will help you make a decision.
I purchased a Dell Precision 3520 with Xeon processor, 32 GB RAM, 512 GB SSD (Samsung N.2), etc. I think I paid $3,500 for it. It's WAY overkill for Dragon. You can get by easily with a $1,000 laptop -- even a Microsoft Surface laptop.
There are two options: installed locally on machine (limited to Dragon Medical Practice Edition) and using the cloud (Dragon Medical One or M*modal). Each has its own advantages.
I use Dragon Medical Practice Edition v4. I prefer it over Dragon Medical One, which is limited in functionality and doesn't seem to be as accurate (to its credit, I haven't used it that much to train it). DMPE4 is $1700 initially and upgrades to major versions are about $5-600. DMO is $99-120/month depending on how you subscribe (there is a discount if you use DMPE4). I subscribed because I was testing it at work. With DMO, you can pay an additional $20/month to use your iPhone/Android as a microphone. Basically you dictate into your phone with an app and it shows up on the hospital computer in near-real time.
You'll need to purchase a microphone... M*modal seems to use Olympus microphones. DMPE4 can be used with the Nuance PowerMic, but I prefer the Philips SpeechMike microphones (I own an SMP3700 wired and an SMP4000 wireless, which I almost always use). These are about $350-450 (wired vs wireless). The wireless does require use of their charging dock which also is a Bluetooth dongle. It's not the easiest to transport and can get by with 1 USB connection, but it's best to use another USB to charge it. They recommend a dedicated power plug for the USB that powers the cradle and charges the device. However, I use my laptops passthrough charging USB port without any problems.
I use Epic connecting via Citrix Receiver. We have a dedicated employee wifi at my health system that's pretty fast. I wish they would allow us to connect by plugging into ethernet, but that's a story for another day.
With DMO, I found a way to make it run off a USB flash drive and I can use Nuance's PowerMic because it's preconfigured somehow with our hospital's network (I think this is what they use for Nuance PowerScribe in radiology and the offices, which is why the PowerMic pops up automatically).
I much much prefer my local edition of DMPE4 and would highly recommend it. I've created several macros (which you can create as autotexts in DMO and likely with M*modal). I can say "macro differential appendicitis" and it will bring up a prepopulated text. I can hit the right arrow button on my SpeechMike and it cycles between {}'s. So I might have {Point-of-care urine pregnancy test.} If I hit the right arrow/next button on the microphone, it will highlight everything between the {}'s. I can then say "delete that" and it takes it out for a male. If I have a bunch of {}'s in the chart with defaults (i.e., {aspirin 324 mg to be given}), I can hit F2 on my microphone to "clear delimiters" that erases all the {}'s. This is good for scoring systems like the HEART score, SIRS, Canadian CT head rule, etc. Basically I have things defaulting to {0}, {negative}, or {no} for decision rules. If people don't meet the Canadian head CT rule or NEXUS head CT rule, I simply say "macro nexus head CT rule", hit F2, and it puts a negative screening tool in my chart. This is one of the reasons why my MIPS scores have been really high (99-100% each month).
One of the benefits to bringing your own laptop is auto-logins for state PDMP's, our hospitalist schedule, our work schedules, PerfectServe (app we use to page consultants), etc. I even have scripts written so I can say into Dragon "launch drug database" and it pulls up my state's PDMP and automatically logs me in.
Other customizations with the SpeechMike: open the billing credit dialog box, hit F1, and it automatically enters my name and closes dialog box. F2 clears delimiters. F3 refreshes chart. F4 puts in a resident attestation note with ability to add physical exam. EOL signs chart. "i" brings up the dictation box. Ins/Ovr inserts the text from the dictation box into the chart. A command button on the back of the microphone executes a script that puts my username and password into Epic login and automatically logs me in.
In summary, I would recommend purchasing a laptop, purchasing DMPE4, and purchasing a Philips SpeechMike. It takes a bit to configure it, but it will help your workload tremendously. Paying $20/hour for a scribe over a 10 hour shift means you have to see a couple more patients in a shift to pay for it. Your setup will pay for itself in the first month. Dictation coupled with macros for physical exams and review of systems will cut your charting time down to a minimum. I can complete a chart in about 1-2 minutes usually unless it's a complicated chart (I've never timed myself, this is an estimate after doing thousands of charts with Dragon). I usually open the dictation box, start dictating, and then navigate the ROS, physical exam, procedures, etc. tabs and click on those checkboxes/insert macroblocks while I'm still dictating. Then I hit the back button/previous button on the microphone to bring up the next {***} (hard stop for Epic) where it will highlight them under HPI, MDM, etc. and insert the appropriate text by hitting the Ins/Ovr button.
The only downside to dictation is that it takes a little bit of time to train recognition (although DMPE4 seemed to be 99% first time I used it). You have to incorporate your medical staff names into DMPE by importing them. Then you can associate names with pronunciations (speak Dr. Agharwal, say correct that, and then either choose their name from the list or type it and then say "choose" followed by the number associated with it). DMPE will learn and after you save/reopen the speech profile, it will recognize their name almost always. You can do this with regular words as well.
Any software recognition program also requires that you proofread things. Examples of things that Dragon has missed with me in the past: patient prepped and raped in the usual sterile fashion (instead of prepped and draped), history of eating hemorrhoids (instead of bleeding hemorrhoids), history of tickle dick syndrome (instead of Pickwickian syndrome), 26-year-old male with no sniffing past medical history (instead of significant past medical history), etc. Recently I had a patient go into SVT and then VT (septic, DKA, myocarditis). I dictated "the nurse pulled Adenocard out of the Omnicell, but it was never given." DMPE translated it as "a dental card" which is the first time it's ever done that despite saying Adenocard numerous times. I find the errors happen when I'm tired after a long shift and start slurring my words in my typical Southern accent. I also speak very fast and have found accuracy to approach 100% with slowing down. It has overcome my Southern accent.
If you choose to go with this and need help setting it up, please don't hesitate to PM me and I'll do what I can (I'm not that familiar with Cerner). I can help you get set up with macros for differentials, scoring systems, etc.
I can't believe they make you pay for your own scribes. I hope you are making $300 plus an hour.
I have both scribes and dictation. I use them each for every chart for different parts.
Scribes do the HPI narrative, click boxes for HPI/ROS/PE. I fill in the MDM, Re-evals.
I wouldn't have it any other way. My scribes are great.
I can't believe you have to pay for your scribes. Also, dictation software should be standard.
Scribes do the HPI narrative, click boxes for HPI/ROS/PE. I fill in the MDM, Re-evals.
I wouldn't have it any other way. My scribes are great.
I can't believe you have to pay for your scribes. Also, dictation software should be standard.
Agreed.
We only have Dragon, but seriously, I would never PAY for scribes. We don't pay for nurses or techs or secretaries, so why would we pay for this specific subset of ancillary staff?
These are amazing. I would love to see a compilation of everyone's speech recognition typos.
Thanks for the detailed post regarding your setup. It seems like the time and money you've spent on fine-tuning this has been a worthwhile investment. Like you, I'm willing to take the time needed to optimize my workflow, including experimenting with different software programs, creating macros, etc. But I think the majority of EM docs don't have the willingness or technical savvy to create such a setup for themselves.
I know this has been discussed endlessly, but I can't believe the crazy state of our EMRs. We are all forced to used clunky, dated systems, which involve spend days in computer training to learn the basic functionality of a given system. But if you're interested in working efficiently with your EMR you'll then need to spend thousands of dollars on equipment and software, plus dozens of hours creating your own macros and smartphrases. Or, like some of you do now, you can choose to spend $20k+ per year of your own money on scribes to allow us to work effectively and not have to spend hours of time after shifts on documentation.
How did we get here? This is insane.
Honestly, I think it's because non-surgeons are bad at demanding excellence from their tools.
In Radiology, we cannot work without proper integration between PACS/EMR/RIS/Dictation system. Because of that, we generally have better IT tools than most physicians in the hospital. But you have to demand it and be prepared to show why you need it.
Scribes are a temporary solution for a problem created out of physician reluctance to demand tools that fit our workflow.
In Radiology, we cannot work without proper integration between PACS/EMR/RIS/Dictation system. Because of that, we generally have better IT tools than most physicians in the hospital. But you have to demand it and be prepared to show why you need it.
Scribes are a temporary solution for a problem created out of physician reluctance to demand tools that fit our workflow.
Most of our bad EMRs are related to all the nonsense things we have to document for billing and medicolegal.
Our chart really should just be chief complaint, a paragraph of MDM and diagnosis. That's it.
Our chart really should just be chief complaint, a paragraph of MDM and diagnosis. That's it.
We have dragon. Its pretty good. Two recent interesting transcriptions:
"she dropped the object on her two toes" --> "she dropped the object on HER-2 toes."
and "high dose albuterol" --> "hydrocyle butyryl"
"she dropped the object on her two toes" --> "she dropped the object on HER-2 toes."
and "high dose albuterol" --> "hydrocyle butyryl"
Disagree.
Scribes and dictation software are synergistic. Scribes enable me to see 4 patients back-to-back-to-back-to back, then go and do a quick I&D, and have my charts done by the time I return to my seat.
We all pay for our scribes. Where do you think the money comes from?
Whether you work for a CMG or an SDG, 100% of the revenue comes from you seeing patients. Your malpractice, payroll, billing, scribes, all that stuff comes from your revenue. Whether your CMG takes more money and makes scribes free, or takes less money and have you pay scribes, it's all coming from your revenue.
No I don't make $300/hr, last two years made $250/hr. Scribes cost about $15-$18/hr overall.
Whether you work for a CMG or an SDG, 100% of the revenue comes from you seeing patients. Your malpractice, payroll, billing, scribes, all that stuff comes from your revenue. Whether your CMG takes more money and makes scribes free, or takes less money and have you pay scribes, it's all coming from your revenue.
No I don't make $300/hr, last two years made $250/hr. Scribes cost about $15-$18/hr overall.
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I disagree with this as well. At our facility, we use scribes, PA's, and see 2.3/hr because that's the only way we can support a salary of $275/hr. It's purely a factor of our payor mix. If we worked in a wealthy area where people had money, I suspect that we would have better coverage, see 1.5/hr, and probably not use scribes because I can do 15 charts/shift without much interruption in my workflow.
You could argue that our workflow and tools prevent us from seeing 2.3/hr, but the tools don't exist that allow me to easily write a chart in 2 mins...at least the way I chart.
I suppose in theory your statement might be correct, but it's like demanding a star trek tricorder to make my job easier.
Prob need a focused exam too.
"60 yo man p/w complaint of painless abdominal swelling. Physical exam shows no abd swelling and a non-tender abdomen. Pt is reassured of no emergency pathology. He is very appreciative of the visit and will see his doctor."
Southerndoc, thanks for the time putting together this post. I'm going to read it over a few times. For what it's worth I use Cerner and we don't have those {} thingies. (I also use Epic at another job so I know what you are talking about).
You can change the delimiters to whatever you want. Epic uses {} and *** (for a hard stop). The default for Dragon is [], but you can change it. I'm sure Cerner has an equivalent.
I have been using Cerner for 4+ years, and as far as I know Cerner doesn't have {} [] *** stuff like that that prevents you from saving a note until you fill it in. I could be wrong though. Anyone else use Cerner and know that?
My other job I work at part time uses Epic and dragon is installed on all the computers. I don't use it because...well namely I haven't asked. I see like 1/hr so I just type all my notes. I F2 through them extremely quickly.
Hmm...maybe I can practice with Dragon at my other job to see if I like it! Hmm
I have been using Cerner for 4+ years, and as far as I know Cerner doesn't have {} [] *** stuff like that that prevents you from saving a note until you fill it in. I could be wrong though. Anyone else use Cerner and know that?
My other job I work at part time uses Epic and dragon is installed on all the computers. I don't use it because...well namely I haven't asked. I see like 1/hr so I just type all my notes. I F2 through them extremely quickly.
Hmm...maybe I can practice with Dragon at my other job to see if I like it! Hmm
4+ years of Cerner here. Never seen a hard-stop like described above.
Agreed.
