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Two New Healthcare Standards to Aid in Data Capture

Capturing data accurately and effectively is absolutely essential in the healthcare realm. Two new standards have recently been developed by ASTM Committee E31 on Healthcare Informatics to facilitate improvements in data capture through both the dictation process and speech recognition technology. Both of these standards, E 2344, Guide for Data Capture through the Dictation Process, and E 2364, Guide to Speech Recognition Technology Products in Health Care, are under the jurisdiction of Subcommittee E31.22 on Health Information Transcription and Documentation.

According to Brenda Hurley, director of industry relations of MedWare, Inc., and chair of Subcommittee E31.22, work on the dictation guide began following a report issued by the Institute of Medicine detailing medical errors and recommending the elimination of handwritten clinical data. Handwriting is currently the most used form of data capture in healthcare documentation, so healthcare providers who use handwriting for data capture may choose to use dictation instead.

“Quality documentation begins with quality dictation,” says Hurley. “Many times the quality of the final transcribed document is hindered by poor dictation habits, distractions to the dictator, or the environment where the dictation is performed.” Hurley says that problems with dictation can lead to delayed report completion, which, in turn, can compromise the quality of patient care.

Some of the topics covered in E 2344 include reducing turnaround time for report completion, enhancing patient safety with completed quality documentation available in a timely manner, and defining appropriate dictation environments for the security of content and recording optimization.

Hurley feels that E 2364 will be a timely and useful tool for healthcare providers who are evaluating speech recognition systems with which to capture data. The scope of this guide is to identify types of speech recognition systems and describe features and benefits of systems used to create medical documentation.

The guide defines the types of speech recognition products that currently exist, how each type is used, and provides scenarios in which speech recognition systems are most widely used in healthcare environments. In addition, the guide addresses the benefits of speech recognition technology, as well as some common misconceptions.

For further technical information, contact Brenda Hurley, MedWare Inc., Orlando, Fla. (phone: 407/475-3300, ext 230). Committee E31 meets Nov. 8-10 during the November Committee Week in Washington, D.C. For membership or meeting details, contact Dan Smith, ASTM International (phone: 610/832-9727). //

Copyright 2004, ASTM International