Speech-recognition technology is increasingly helping U.S. military doctors keep more detailed patients notes while cutting the time they spend typing on their computers.

By 2011, the U.S. Department of Defense expects to have implemented its integrated, interoperable electronic medical record system -- AHLTA -- at more than 500 military medical facilities and hospitals worldwide.

The system will be used for the care of more than 9 million active military personnel, retirees, and their dependents. Military doctors using the AHLTA system also have access to Dragon NaturallySpeaking Medical speech-recognition technology from Nuance Communications' Dictaphone health care division, allowing doctors to speak "notes" into patient records, as an alternative to typing and dictation. Over the last year, the adoption of Dragon has doubled, with about 6,000 U.S. military doctors using the software at health care facilities of all military branches, including the Air Force, Army, Navy, and Marine Corps.

AHLTA was originally designed as a surveillance system to pick up on symptoms that could indicate a health problem that's developing in military personnel, said Dr. Robert Bell Walker, European Regional Medical Command AHLTA consultant and a family practice physician for the military. And as part of that original plan, AHLTA started out as an "all structured text" system. That means it was "very rigid and burdensome" for physicians to use while entering information about patients. Over time, the military has allowed the use of "free text," and more recently voice, to more easily capture physician notes and other patient information while caring for patients, he said.

The use of Dragon Naturally Speaking voice-recognition software with the AHLTA e-health record systems is freeing doctors from several hours of typing into the AHLTA their various patient notes each week, he said.

Being able to speak notes into an e-health record at the patient beside -- rather than staring at a computer screen typing -- also helps improves doctors' bedside manner and allows them to narrate more comprehensive notes while the patients are there, or right after a visit. That cuts down on mistakes caused by memory lapses and boosts the level of details that are included in a patient record, Walker said.

The voice capability "saves a lot of time and adds to the thoroughness of notes from a medical and legal aspect," said Dr. Craig Rohan, a U.S. Air Force pediatrician at Peterson Air Force base in Colorado. The ability to speak notes directly into a patient's electronic chart is particularly helpful in complicated cases, where a patient's medical history is complex, he said. Text pops up on the computer screen immediately after words are spoken into the system, so doctors can check the accuracy, make changes, or add other details.

Also, because spoken words are immediately turned into text, the medical record has "a better flow" to document patient visits. Previously, "the notes that had been created by [entering] structured text into the AHLTA system looks more like a ransom note," said Walker, with information seemingly randomly pasted together.

Doctors can speak into a microphone on their lapels to capture notes in tablet PCs during patient visits, or speak into headsets attached to desktop or wall-mounted computers.

Also, macros allow health care providers to create special functions for spoken commands. So, for instance, a computer screen will automatically display a checklist of questions about developmental milestones to ask the parent of a 2-month-old patient or a checklist of care that a diabetic patient should receive.

So, if a diabetic patient hasn't had a foot exam recently, the system can help remind doctor. "The macros are a big benefit," said Walker. They help military doctors to adhere to clinical practice guidelines and reduce the variables in care, he said.

The storage requirement of voice notes is "small," especially when compared with other records, such as medical images, said Walker. With the ongoing wars in Iraq and Afghanistan, there has been "100% turnover" in the doctors staffing some military medical facilities, such as the one in Heidelberg, Germany, where Walker works, he said.

Many of the physicians at these bases are military reservists who have 90-day or one-year service deployments, said Walker. So training on the AHLTA system -- and the voice-recognition features -- is a constant, he said. But once doctors move onto to other facilities, or even back to their private practices, the training pays off -- they see how they can use voice recognition in their own workflow back home, he said.

For certain, doctors of the U.S. Military Health System aren't the first or only health care providers using speech recognition to enhance patient records. In the private health care sector, Dragon speech-recognition products are also being used to supplement information in e-health records systems, as well as replace traditional medical dictation and transcription processes.

Mount Carmel St. Ann's hospital in Columbus, Ohio, has been among the early wave of health care providers using electronic clinical systems bolstered with speech-recognition capabilities. About seven years ago, emergency department doctors at Mount Carmel St. Ann's hospital began having access to Dragon's speech-recognition software not long after an e-health record system from Allscripts was rolled out there.

When the e-health record was first rolled out -- without the voice capabilities -- Mount Carmel St. Ann's doctors didn't necessarily see the kind of productivity boost they had been hoping for, in large part because they found themselves spending a lot of time typing notes, said Dr. Loren Leidheiser, chairman and director of emergency medicine at Mount Carmel St. Ann's emergency department. But as more Mount Carmel St. Ann's ER doctors began incorporating the speech-recognition capabilities into their workflow -- whether speaking notes into a lapel microphone or into a computer in the patient room or hallway -- the efficiency picked up tremendously, said Leidheiser.

Also, before using the Dragon software, the ER department spent about $500,000 annually in traditional dictation transcription costs for the care associated with the hospital's 60,000 to 70,000 patient visits yearly at the time. That was cut down "to zero," he said. The return on investment on the speech recognition, combined with the use of the e-health record system, was "within a year and a half," he said.

Leidheiser also makes use of time stuck in traffic to dictate notes that are later incorporated into patient records or turned into e-mails or letters. Using a Sony digital recorder, Leidheiser can dictate a letter or note while in his car, then later plug the recorder into his desktop computer, where his spoken words are converted to text.

By adding spoken notes to medical records, e-mails, and letters, "it's easier to tell the story," he said.