Digital dictation: cost-saver or efficiency-gainer?

Digital dictation is taking off in the NHS, largely because at the press of a button the files can be sent to a transcription service on the other side of the world. But digital dictation (DD) systems have gained a reputation for involving big upfront costs, for both software licences and hardware, and such capital spending requires specific managerial approval. To tackle this, a number of suppliers are offering DD facilities on a software-as-a-service basis across the internet. This means that trusts no longer have to tap scarce capital funding and can instead pay for the service as they use it out of operating budgets. NHS Salford is one trust using DD on this basis. It uses WinScribe's service at its Walkden Gateway Clinic, a health centre which is jointly maintained and serviced by the local council and the NHS. The web-based dictation system has been active since the centre opened in September 2008. Where analogue tapes were used previously - taking up to three weeks to transcribe patient notes and relay the printed words to the patient's GP - WinScribe's OnDemand technology means that the notes often come back, fully transcribed, during the same half-day session. "It's a web-based system that allows our staff to dictate the notes into the computer and send them off securely to a transcription centre in the US, where it is transcribed and sent back," says consultant physiotherapist Victoria Dickens. So why not simply get the staff to keyboard-enter the data themselves at the point of clinical care? According to Dickens, there's just too much data to enter and, in any case, it's not a good use of NHS funds for a trained physio to perform secretarial duties. Staff at Colchester General Hospital tell a similar story. The Essex hospital has five secretaries, more than 30 patient-facing staff, as well as ultrasound technicians, radiographers and consultants spanning five sites. This made the physical handling of audio cassettes - including shuttling them between sites - a logistical nightmare. Switching to DD was a logical move, especially after the hospital's IT systems crashed for nine days in March 2005, making analogue transcription impossible. Radiology services manager Sue Maughn worked with the hospital's clinical director Martin Gould to commission a system from G2 Speech, whose system is based on Philips DD technology. According to Maughn, switching to DD has allows secretarial staff to prioritise which tasks needs to be done and in which order through the software. "You can even dictate and use Windows applications at the same time," she says, describing the ergonomics of DD technology as perfect. A national conversation While staff at Walkden and Colchester are keen adopters of DD, what about the national view? Are trusts adopting the technology because of the clinical care advantages, or are the economic benefits alone driving its adoption? Chris Hart, chief executive of DD specialist SRC, argues that both ongoing cost and clinical advantages are apparent. Hart, whose company has signed technology agreements with a number of NHS procurement hubs, says that most consultants and medical staff are well used to dictating their notes, so it does not matter whether the technology is analogue tape or DD. "The main advantage we see stems from the use of the technology in acute departments, where you get a lot of patient throughput and there is lot of human contact involved," he says. "The last thing you want is a doctor typing between patients." He adds that SRC is also starting to see trusts integrating DD technology with their electronic health records (EHR) systems, including West Sussex and Chichester hospitals. It is possible to improve efficiency at the same time as improving patient care, he argues. "Take the example of Brighton and Sussex University Hospitals Trust - they use barcoded capture and DD to speed the transcription process. Once the transcribed text comes back, the admin staff can load up a patient letter template and populate the letter with data from the transcribed text," he says. "Using this approach means that the letter file can then be checked and approved by the doctor - and off it goes." Legacy systems can be accommodated by using software modules that interface between the SRC dictation platform and specific third party applications or - where the modules have not been developed for a given legacy package - using standard open database connectivity protocols. But James Kippenberger, healthcare director of rival DD vendor BigHand, says that integration with EHR and other systems is far from universal, however, although some trusts including Mid-Yorkshire have integrated the technology, "What they have done is to create an intermediate step between the file being dictated and typed. If a member of staff accesses the patient's record in the interim, they can click on the audio file and listen to it," he says. Kippenberger is also seeing trusts starting to move away from the need for text based EHRs and notes, and an increasing interest in digital streaming. Young staff coming into the NHS are comfortable with audio-visual files being streamed on the internet, so medical staff are starting to append the spoken words of the patient to their medical files. "GPs know that their patients can describe their type of pain far more effectively using the spoken word rather than text based notes. Moving to audio attachments to patient notes makes a lot of sense in these situations," he says.