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Commissioning and Implementing Digital Voice and Referral Managment Solutions It’s a New Day for Referral Management Speech Recognition Systems Living with NHS Budget Cuts Being a General Practice Clinician Faster, More Accurate and Financially Sound

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Commissioning and Implementing Digital Voice and Referral Managment Solutions It’s a New Day for Referral Management Speech Recognition Systems


Living with NHS Budget Cuts Being a General Practice Clinician Faster, More Accurate and Financially Sound



John Hancock, Editor

It’s a New Day for Referral Management


John Bendall, Director of UK Operations, Crescendo Systems Limited

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Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom

Digital Dictation (DD): The Cornerstone Speech Recognition (SR): from Fantasy to Value for Money Clinical Systems Integration: The Accelerator Advanced Clinical Reporting: Knowledge is Power

Speech Recognition Systems


John Hancock, Editor

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Voice and Speech Recognition Pros and Cons Where Speech Recognition Systems Are Used Application in Medical General Practice

Publisher Kevin Bell

Living with NHS Budget Cuts

Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit:

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. © 2016. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.


Camilla Slade, Staff Writer

General Practice is Not Simple Looking Towards 2020 Taking Note of the Patient Keeping the Record Straight Referrals Management Saving Costs and Improving the Service Cutting Waiting Times

Being a General Practice Clinician


Peter Dunwell, Medical Correspondent

The Challenges of Being a GP Technology: The Way Forward General Practice: Always a Challenge What Records do for the Practice When a GP Must Refer a Patient to a Specialist

Faster, More Accurate and Financially Sound


John Hancock, Editor

Technology: The Way Forward Speech Recognition: Supporting the GP and Supporting the Patient Better Use of People and Their Time Indirect to Direct Inputs Key Factors When Selecting Speech Recognition Software

References 15



Foreword F

ROM ROOM-SIZED boxes of technology that

In the second piece, we take a closer look at speech

required input to be from a keyboard via a

recognition systems, their history and the capability

punched paper tape, computers have evolved

that they can bring to any workplace to improve not

more rapidly than any previous technology, to

only productivity, through the time they save, but also

become the ubiquitous accompaniment to life that

quality of outcomes, through their accuracy. Next,

we know today. And now, the ultimate evolution is

Camilla Slade returns to a familiar theme of NHS

taking place - the absorption of IT power into our

reorganisation and inevitably budget restraints, to see

normal actions using direct input technologies.

how voice recognition is deployed to help practices

These new input methods offer a more natural

get more outcomes for fewer resources. She cites

and comprehensive leveraging of IT power and

some case studies of situations with which any GP

none more so than speech recognition. This is a

will be very familiar. Peter Dunwell’s article delves

technology that will revolutionise many workplaces

further into the world of general practice and, in

and is especially relevant where time and quality

particular, to the wide and diverse variety of tasks and

pressures are the norm. Sound familiar? General

responsibilities that comprise a GP’s work day. Finally,

practices are among the busiest and most

we consider how a speech recognition system can

pressured work environments and where a solution

work with a general practice and some of the practical

such as speech recognition is ideally suited to add

considerations that a GP will need to take into account

value to clinicians’ work and patients’ experience.

before embarking on this technology.

This Special Report opens with an article by John

While no technology can replace the GP’s medical

Bendall, Director of UK Operations at Crescendo

skill, speech recognition can ensure the best use of

Systems Limited, that looks at the latest technology

that skill.

advances that are having a positive impact on practices and CCGs. These include digital dictation systems and speech recognition, which have transformed the workload of GPs, as well as creating significant savings.

Tom Cropper Editor

John Hancock has been Editor of Primary Care Reports since launch. A journalist for more than 25 years, John has written and edited articles, papers and books on a range of medical, management and technology topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management, and NHS management and reforms.



It’s a New Day for Referral Management John Bendall, Director of UK Operations, Crescendo Systems Limited Why the latest technology advances are changing the game for practices and CCGs – today more than ever before.


eneral practitioners make more than 9 million referrals each year, triggering many billions of pounds of expenditure. Still, according to Imison and Naylor, “GPs’ capacity to refer appropriately would be greatly strengthened by access to decisionsupport tools, up-to-date information on local services, and regular feedback from audit of their referral activity.” Relying on the right technology to record detailed patient records is all the more critical today as medical records are now open for patient access and GPs need to protect themselves against possible medico-legal issues. The good news is that increasing challenges are not arising alone: they can be met today in ways that were not available yesterday. While 10-minute consultations, shortage of GPs and exploding workload are putting General Practice under more pressure than ever before, Digital Dictation Systems (DD) and Speech Recognition Systems (SR) have evolved to transform what used to be an absolute burden into a source of great savings.

1. Digital Dictation (DD): The Cornerstone It starts with voice, but doesn’t end there. Choosing the right digital dictation system requires more than selecting the best sound quality. So let’s get it out of the way with some simple advice: stay clear from systems which create and copy large .DSS and .WAV files around your network and search for a system that streams voice in realtime. This will guarantee optimal sound quality at any point in time with zero impact on your internal network and N3 speed. Now let’s discuss the core requirements: regardless of how many doctors, secretaries, supervisors and branches your practice has, your DD system must support any scenario – and by any, I mean any. This starts with the system’s ability to support multiple input methods: from Philips or Olympus dictation devices all the way to the latest Smartphone with a free-to-use app.

What about daily ease of use: can you create and sign off a dictation without having to touch the mouse or keyboard? Do you have to minimize and maximize different screens all the time? Can the system take you straight back to your patient record screen automatically? These are questions you should be asking from the outset. Real-Time: To be or not to be If your practice is spread over several sites, real-time turns out to be, again, the only viable option if you want to pool secretarial resources: if it takes an hour to copy an urgent voice file to Secretary A who is totally overworked, the patient will have to wait since there was no way to know that Secretary B was free to type it right away other than by calling or visiting her. The problem with most systems is that they are typically deployed at practice level. As a result, multi-site practices and CCGs can end up with two or three different systems to maintain, and most importantly, they can’t reap the massive benefits offered by a central, integrated deployment. By central, I mean business: all dictations must be hosted and managed on a central server (as in ‘deployed on a virtual server with all practices connecting to it via the N3’). Files are then streamed on demand – as opposed to copied



The problem with most systems is that they are typically deployed at practice level. As a result, multi-site practices and CCGs can end up with two or three different systems to maintain, and most importantly, they can’t reap the massive benefits offered by a central, integrated deployment

back and forth – to and from the central server directly via the NHS N3 network. While this means instant access for the secretaries, it also means real-time workload visibility for the management staff. ‘Being dictated’, ‘dictation complete’, ‘routed’, ‘being typed’, ‘transcription complete’, ‘signed off’, ‘distributed’: you now know what’s going on with “Sarah Jones’s ENT referral” since it’s always been right where it belongs: on the central server.

2. Speech Recognition (SR): from Fantasy to Value for Money Speech Recognition has been on everyone’s lips for several years. It’s now in everyone’s hands, with a high level of confidence brought in by equally high levels of accuracy. With a decade-long development track record, 90 medical dictionaries, up to 99% out-of-the-box accuracy and zero training approach, Dragon is the most proven system out there and, as we speak, nothing else comes close. Crescendo’s integrated solution is powered by the latest Dragon Medical Practice Edition, which offers up to 20% better accuracy than previous Dragon versions and requires virtually no training. Not to mention its impressive ability to learn from its own mistakes in the background. But for practices involving entire teams in a rather complex documentation workflow, accuracy is only the beginning of the win-win recipe.

off. As for locums and registrars, they might just want to do straightforward digital dictation. Practices should be able to activate speech recognition for certain doctors or referral types only, depending on their specific needs. Because flexibility is the real productivity booster, Crescendo has designed an integrated solution that allows doctors to switch between digital dictation, front-end, back-end speech recognition or a combination of all three modes at any time. But that specific choice should not prevent them from accessing other key features offered by front-end speech recognition, such as the ability to navigate around their clinical system and add medication and consultation notes by voice directly to the patient file. Using the same engine front and back-end means that the system learns two-fold: corrections made in one mode are made available to the other, so the system learns much faster.

One license per voice: the icing on the invoice Using the same engine for either mode means that you only need to purchase one license per voice, which will significantly reduce the investment and accelerate the payback. Similarly, there is only one maintenance fee to keep the software up to date, which will lower running costs and enhance the life of the products for year to come. Add workflow flexibility to recognition accuracy and you start seeing the tasty figures line up. Most systems out there still require doctors to choose between DD and SR, or between frontend SR and back-end SR. This equates to forcing them into creating their own referrals, even if they don’t have time for that. Well, I thought technology was supposed to adapt to users’ workflows and make their life easier, not the other way around. Certain doctors will want to produce their own referrals right away, while others will prefer dictating notes on the fly and route them to secretaries in the background for a later sign 4 | WWW.PRIMARYCAREREPORTS.CO.UK

3. Clinical Systems Integration: The Accelerator Clinical system integration is our problem, not yours. That’s right: it’s up to the supplier’s technical experts to work out any technical roadblocks and provide you with a solution that guarantees automatic labeling of demographics into the report. In addition to eliminating the risk of referrals being associated with the wrong patient, proper integration speeds up the dictation and typing process. Here is what happens when clinicians dictate with Crescendo at the point of referral: they are asked to select, in addition to the automated


patient demographic entry, the specialty and referral type from a customisable “smart list”, which can mirror NHS England’s E-referral service specialties and clinics. This data is then captured by the system, so the next logical step is for the system to provide a real-time snapshot of the data along with detailed, customisable, specialty and referral reports. Outsourced Transcription: Silver Lining Outsourcing is one of those hot-potato topics that seems to burn everyone’s mouth: “is it secure?”, “it’s complicated”, “it’s expensive”, “I find it hard to integrate with the dictation system in place”. This is what led Crescendo and DICT8 to join forces and simplify the whole process, putting a definite and cost-cutting end to blocked transcription funnels.

your exact workflow using secure/encrypted file transfer directly back to your practice or via a web view and download option.

4. Advanced Clinical Reporting: Knowledge is Power Everybody agrees that a DD system is able to shrink turnaround times from days to hours and sometimes minutes while taking GP and secretary productivity to where it should be: a good place. But that still leaves a key question unanswered: can your system ALSO shed light on referral patterns for you? Yes it can, provided it ticks the “Central Server” and “Real-Time” boxes. It’s only logical if you think about it: a DD system automates the entire referral creation and typing workflow. It keeps track of not only what was dictated and typed when and where, but also by whom and for which Patient ID from the Clinical System. It can also prompt the clinician for the specialty and referral type at the outset. So refusing to pull up a fullfledged referral report at any point in time would be a rather lazy move for a DD system, knowing that it’s got all the data in store.

Automate transcription outsourcing to UK based, Grade 4 Medical Secretaries when you most need them. Based on user rights and system configuration, this outsourcing option can be made available to authors, transcribers and administrators. Here is an overview of key user and system actions: • Authors can select which dictations are sent for off-site transcription. • Transcribers can choose to re-route dictations for off-site transcription. • Administrators can batch assign dictations for off-site transcription. • The system can be set up to only send dictations off-site based on the work type or turnaround and trigger times (e.g.: attendance notes that have been in queue for more than 48 hours). At any time, you can run a detailed report of which work has been sent for off-site transcription, allowing you to compare the data against DICT8’s invoices. As the dictation activity is tracked from export to final import, you can even produce turnaround reports to ensure that the predefined turnaround times have been met by DICT8. As for the document return service, it is provided by DICT8 and can be tuned to match

Never without my Dashboard Having a proper Referral Management Dashboard yields savings that could pay for your investment within a year or two. The ‘front screen’ of the dashboard provides you with a real-time view of your highest referring GP’s and your most efficient secretaries. There is also a live count of the number of referrals current, pending and awaiting transcription with average turnaround time from dictation to transcription displayed in hours and minutes. Drilling into the reports allows you to: •T rack Referrals in real-time: Detailed breakdowns by specialty, type, practice and individual GP lets you see exactly what is going on, when and where. •A nalyse Referral Trends: The dashboard can tell you, in just a few clicks, who are the higher referring practices/doctors. And that’s WWW.PRIMARYCAREREPORTS.CO.UK | 5


Having a proper Referral Management Dashboard yields savings that could pay for your investment within a year or two

just one example of the many detailed reports you can get for any given period, including year-on-year. •C ontrol Referral Costs: You can validate actual use of lower cost, community based services while ensuring over-average referrers are bought into line with the rest of the CCG. Icing on the real-time cake: you can also measure the use of Local Enhanced Services. Move work around, not people Because your files are handled by a central server, they can be shared securely with any typing resource at any location connected to the N3. Urgent work can be automatically routed based on referral priority and type, specialty, doctor or branch. You can see what referrals are scheduled to be done, waiting to be typed or being typed, with alerts to potential backlogs and approaching deadlines so you can react immediately: in just a few clicks, you can reallocate work to where the required resource is available – and with the amount of resources you already have at each surgery, you should never have to hire another temp. Does this mean that each surgery ceases to manage their own referrals? Not at all, and that’s another beauty of it all: having a central, real-time system won’t hinder local ways of doing things, it will simply provide a safe architecture around them while making available instant back-up for urgent and overflow work.


Because your files are handled by a central server, they can be shared securely with any typing resource at any location connected to the N3


Speech Recognition Systems John Hancock, Editor Speaking control of your work

Voice and Speech Recognition Voice recognition and speech recognition is an alternative to typing copy and instructions to a PC or other device. The user just talks to the computer through a microphone and their words appear on the screen or their instructions are carried out. Speech recognition systems have evolved a long way to the all-encompassing voice activated capabilities of today. According to PC World1, in the very early days in 1952, Bell Laboratories designed a system called ‘Audrey’ that could understand digits. Ten years later, in 1962, IBM’s Shoebox could understand words, albeit just 16 words. However, the idea enjoyed significant progress in the 1970s when funding from the US Department of Defense resulted in a system with a vocabulary in excess of one thousand words. The 1980s saw the ’word-byword’ dictation style required by early systems develop into “a sophisticated system that responds to fluently spoken natural language and takes into account the varying statistics of the language in which the speech is produced.”2 Today, we are all familiar with speech recognition programs that underpin the call filtering element of automated phone systems using interactive voice response (IVR); but, as How Stuff Works3 explains, “A range of software products allows users to dictate to their computer and have their words converted to text in a word processing or e-mail document. You can access function commands, such as opening files and accessing menus, with voice instructions. Some programs are for specific business settings, such as medical or legal transcription.” (author’s italics).

Pros and Cons There are, of course, pros and cons to using speech recognition as an input method. One obvious advantage is that we talk naturally. Speech Empowered Computing4 adds to that that we can become more productive using speech as an input method. Most people dictate up to three times faster than they can type and, of

course, unlike dictating to an assistant, speech recognition users see their work displayed on screen immediately. Plus, of course, using such a system puts a lot less strain on users’ hands to avoid the ‘RSI’ type conditions that afflict those who use a keyboard and mouse all the time. Looking at the bigger picture, Reference.com5 concludes; “There are many advantages to using speech recognition such as improved turnaround, reduced costs, error reduction, and improved and timely decision making.” Although speech recognition is by no means perfect, most of the once-quoted disadvantages have now been eliminated. Accuracy has advanced in leaps and bounds until it is now as good as, if not better than, some people’s typing capabilities; also, modern systems can cope with variable accents and even with, say, a user having a cold that might temporarily change their voice. Similarly, a combination of hardware (microphone) and software improvements mean that most background noise will not detract from a system’s speech recognition. Probably the one disadvantage that remains is the effect on the vocal chords of talking for long periods; but any health practitioner should know how to regulate their activity to cope with that.

Where Speech Recognition Systems Are Used Call centres Probably the largest volume users of voice or speech recognition technology are customer call centres but the systems they use are often fairly basic, responding simply to the inputs that the system requests – ‘Yes’, ‘No’, a number or a name already registered in the system. However, speech recognition can do a lot more than that. Writing Perhaps the most obvious application would be for people who have to write; authors, journalists… The Self Publishing Advice Center6 explains, “The WWW.PRIMARYCAREREPORTS.CO.UK | 7


Seasoned users find that they can manage emails and even social media posts, plus the software can be used on more than one platform so that dictation can be to a smartphone or similar device


latest generation of voice recognition software can be an invaluable tool for indie authors, whether you are writing full-time or trying to make the most of limited time available. Even if you have been deterred by disappointing experiences with earlier packages, it’s worth trying the latest software to see whether it can help you improve your productivity.” But it isn’t simply writing. Seasoned users find that they can manage emails and even social media posts, plus the software can be used on more than one platform so that dictation can be to a smartphone or similar device. Warehousing Other heavy users of voice recognition software are warehouses, which use the voice-directed warehousing software to instruct operators and to register their responses when the requested task has been completed. It has now expanded from that original picking role to handling all warehouse functions. Engineering and maintenance In complex engineering and maintenance processes, a hands-free capability can be invaluable to speed an engineer’s work (no


need to put one thing down in order to use both hands) and even reduce the number of people required to complete a job. Equally, even a mobile device, if it needs a keypad and finger for entry, will hinder work. Voice and speech recognition is increasingly being used as a means to input data to a system, order parts and record each action as it is completed. Military Systems and Technology7 sums it up; “Productivity, parts order accuracy and efficiency would all rise as a result of engineers no longer needing to down tools and take trips to report data back to base, or input data manually.” Application in Medical General Practice If all of this seems a little far off from life in a General Practice environment, it is not the specific tasks that matter but rather the processes and benefits that can be gained. A GP surgery might not be a call centre but, for jobs such as specialist patient referral, the ability to automate based on speech recognition can free up the time of administrative staff. Most importantly, the ability to complete forms and/or patient reports will benefit enormously from applying this technology.


Living with NHS Budget Cuts Camilla Slade, Staff Writer Using technology to improve productivity

General Practice is Not Simple Readers won’t need me to remind them that GP practice is complex and busy. NHS Choices tries to sum it up in a few words8; “GPs deal with a whole range of health problems. They also provide health education, offer advice on smoking and diet, run clinics, give vaccinations and carry out simple surgical operations. GPs usually work in practices as part of a team, which includes nurses, healthcare assistants, practice managers, receptionists and other staff. Practices also work closely with other healthcare professionals, such as health visitors, midwives, mental health services and social care services.” In line with this, according to Citizens Advice9, “80 per cent of GPs report that dealing with non-health issues meant they had less time for other patients’ health needs. If non-health demands could be met in other ways, this could free up GP time to focus on patient healthcare.” In short, “[GPs] focus on the health of the whole person combining physical, psychological and social aspects of care.”10 However, much as we might not like it, GP practices, like every other element of the NHS, do not enjoy unlimited funding. Not only is the budget always an issue, but recent NHS reforms have put GP practices firmly at the centre of healthcare in the NHS. So GPs face two conflicting pressures to do more than before with, if not less, then certainly no more resources.

Looking Towards 2020 This is not the place to go too deeply into NHS reforms except inasmuch as they could have relevance to the use of technology such as speech recognition. Along with the reforms, NHS England has published the ‘General Practice Forward View’11 looking at how GPs should be working by 2020. Together with the proposed changes, there is a plan to devote up to 10.7% of the NHS budget to general practice and a one-off £900m to be spent on improved general practice facilities. Again, this is not the place to discuss that in depth but, among the main points

addressed by the publication and concomitant policy is the objective to achieve a paper-free NHS by 2020 and to free 10% of GP time from bureaucracy. In that context, and with the clear commitment to invest in general practice, speech recognition software can play a significant role.

Taking Note of the Patient Notes are a very important part of any patient management system. First, notes can remind a doctor of a patient’s history and of previous presentations by the patient as well as what was said and implemented at that time. They can help to identify where changes in condition have occurred even when the patient might be unclear on that. Even in a simple, one-off condition, notes can help: where the patient is among that growing population with multiple and complex conditions, notes are central to any decisions. And, in this era of evidence-based diagnosis, they also allow a GP to document the reasoning behind a decision which is medically useful and legally essential in the event of any complaint procedure: for a concise summary, look at GP notebook12. And, of course, when a patient has to move to a new area, the notes will ensure that their new GP is fully informed. However, to do all that, notes need to be comprehensive, achieving which takes time.

Keeping the Record Straight As well as the GP’s own notes taken at consultation, patients accumulate a significant record of reports from hospital visits, from therapy programmes they have attended and from a host of relevant events and activities. These records no longer reside in large filing cabinets but, as the RCGP, BMA and DoH report, ‘The Good Practice Guidelines for GP electronic patient records’13 observes, “Current practice computer systems contain vital records on which patient care depends.” The report continues to explain in depth the purposes to which health records are applied and touches on the paper-free environment that is an objective of the Forward View (above). WWW.PRIMARYCAREREPORTS.CO.UK | 9


The practice’s secretarial team used to spend 25 hours per week just on transcription tasks. This ratio went down to five hours per week once speech recognition was installed, which translates into an 80% saving in staff time REAL TIME PATIENT DATA ANYWHERE

Referrals Management While GPs can handle many of the conditions with which patients present, there will be some that, while the GP can identify them, have to be treated by a specialist. The GP then needs to refer the patient to an appropriate specialist. Part of that referral will include providing a letter to the specialist outlining essential background information, such as the patient’s medical history, and it will also contain details to which the specialist needs to pay particular attention. Referral practice is an important part of GP healthcare and NICE (National Institute for Health and Care Excellence) has published a number of reports on the subject such as the South Norfolk Healthcare Community Interest Company report ‘Quality and Productivity: Proven Case Study’14.

Saving Costs and Improving the Service Although not a UK body, 1st Providers Choice15 in the USA sums up the benefits of voice recognition software in a medical context. “Many doctors are avoiding the hurdle of manually entering patient data by using medical voice recognition software to speak commands and enter patient notes into their e-health record systems. Voice recognition functionality is not only helping to drive utilization of e-health record systems among doctors, it’s also helping to dramatically reduce the cost of medical transcription services.” And there are plenty of examples where UK GP practices have proved this to be true. Voice recognition to do everything Looking at ways to improve efficiency, Talking Point documents a case study ‘From digital 10 | WWW.PRIMARYCAREREPORTS.CO.UK

dictation to voice recognition at Holt Medical Practice’16 describing how, “Holt purchased… the full voice recognition software to offer all its doctors the ability to simply and quickly create clinical notes, patient records and referral letters directly by voice.” The voice recognition package has been so successful at the centre that “100% of those GPs currently trained use this tool to do everything.” An eighty percent saving in staff time Another case study, based on Benfield Park Medical Group in a quite different area, Newcastle upon Tyne, is documented by First Practice Management and boldly titled ‘Can you save £10,000 a year with speech recognition?’17 As Jonathan McCutcheon, Practice Manager, explained, “…once we calculated the actual savings in terms of GP time and increased staffing efficiencies, speech recognition was a no brainer for us. The practice’s secretarial team used to spend 25 hours per week just on transcription tasks. This ratio went down to five hours per week once speech recognition was installed, which translates into an 80% saving in staff time. Speech recognition allowed our practice to take the giant efficiency leap we had been eagerly expecting.” Cutting Waiting Times Perhaps we can leave the last word to the IT Pro article ‘Doctors use speech recognition to cut NHS waiting times’: “… doctors can dictate [referral] letters directly into the web-based Choose and Book service, which is the system used to process referral requests, and send them off while the patient is still in the room.”


Being a General Practice Clinician Peter Dunwell, Medical Correspondent The challenges of a diverse and increasingly demanding population

The Challenges of Being a GP Bring a GP has never been the easy option but that job has become even more challenging in recent times. As The King’s Fund report ‘Understanding pressures in general practice’18 puts it; “General practice is in crisis. Workload has increased substantially in recent years and has not been matched by growth in either funding or in workforce… Pressures on general practice are compounded by the fact that the work is becoming more complex and more intense. This is mainly because of the ageing population, increasing numbers of people with complex conditions, initiatives to move care from hospitals to the community, and rising public expectations.” NHS England19 agrees with this analysis. “Through our recent engagement with general practice, clinical commissioning groups (CCGs) and other partners, we have heard that general practice and wider primary care services face increasingly unsustainable pressures and that general practice wants and needs to transform the way it provides services to reflect these growing challenges.”

Technology: The Way Forward Add to that the 2020 target for paperless NHS mentioned in the preceding article. There will be a number of requirements to be met if that objective is to be achieved including, as cited in Dr Phil Koczan’s article for the National Health Executive (NHE)20, “Unfortunately, many clinicians are disillusioned by technology as, historically, systems have been slow, clunky and difficult to use, particularly during consultations when patients are present. Improvements in technology, mobile devices and techniques such as voice dictation (author’s italics) are beginning to change this perception.” If a service ever needed the support of good quality technology and software, it’s general practice. The National Information Board (NIB) of the NHS21 would agree; “By effectively

harnessing technology to help reshape care delivery, enabled by flexible costing, pricing and payment models, we will drive down variations in quality and cost-effectiveness while improving safety.” Just as in any other business, a general practice can harness the power of technology to deliver better ordering of materials and services, better analyses of patients’ progress through their care plan, better informed decisions and greater control through improved knowledge.

General Practice: Always a Challenge Most GPs would understand this and relish the opportunity to improve their practice service through the deployment of technology. But, even without the challenges of a constrained budget and increased demand, the GP’s job has always been a challenge, which is what attracts doctors. The Royal College of General Practitioners (RCGP) celebrates this reality22; “The joy of general practice is its infinite variety. You simply never know what you will be dealing with next. It could be a simple sore throat, a heart attack, a chest infection, a schizophrenic breakdown, a pregnancy or a convulsing child. Being a brain surgeon may be seen by some as a more glamorous career, but no other branch of medicine has the remarkable variety of general practice.” General practitioners (GPs), as well as treating all the medical conditions mentioned and more, also refer patients to hospitals and other medical services for urgent and specialist treatment. They focus on the health of the whole person combining physical, psychological and social aspects of care. And, of course, different populations in different areas (rural or inner city) bring different challenges. Also, in order to generate economies of scale and offer patients a wider range of services, general practices are growing larger which makes their efficient operation all the more important. WWW.PRIMARYCAREREPORTS.CO.UK | 11


The main reason for maintaining medical records is to ensure continuity of care for the patient. They may also be required for legal purposes if, for example, the patient pursues a claim following a road traffic accident or an injury at work TECHNOLOGY INFORMS REAL TIME DECISION MAKING

What Records do for the Practice Camilla Slade mentioned the importance of record keeping and the General Medical Council23 offers some key advice in this connection… • Keep clear, accurate and legible records. • Make records at the time the events happen, or as soon as possible afterwards. • Record your concerns, including any minor concerns, and the details of any action you have taken, information you have shared and decisions you have made relating to those concerns. • Make sure information that may be relevant to keeping a child or young person safe is available to other clinicians providing care to them. It cannot be over-emphasised that good records are valuable assets for the practice as the Medical Protection Society24 affirms. “The main reason for maintaining medical records is to ensure continuity of care for the patient. They may also be required for legal purposes if, for example, the patient pursues a claim following a road traffic accident or an injury at work. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim…” Any technology that can improve the speed, comprehensiveness and accuracy of record


creation must be a welcome addition to a general practice. As a last word on the matter, NICE suggests of record keeping25, “It is not an optional extra to be fitted in if circumstances allow.”

When a GP Must Refer a Patient to a Specialist Referrals are, arguably, where GPs have most impact on the wider NHS. In order to generate a sound and effective patient referral, a GP needs understanding of the patient, knowledge of the treatments and therapies that might be available and awareness of the available facilities where those treatments and therapies could be delivered or where the specialist knowledge that might better diagnose a condition might be found. As long ago as 2010, The King’s Fund 26 confirmed, “General practitioners (GPs) make more than 9 million referrals to hospitals for elective (planned) care each year (Hospital Episode Statistics 2008), referrals that then trigger billions of pounds of National Health Service (NHS) spending. Referral management schemes attempt to influence and control patient referrals, predominantly those by GPs, either directly or indirectly.” These figures will certainly have increased by now which makes the efficient management of referrals all the more important.


Faster, More Accurate and Financially Sound John Hancock, Editor Speech recognition in the context of a general practice

Technology: The Way Forward

Healthy scepticism

In the 2013 report ‘A review of the potential benefits from the better use of information and technology in Health and Social Care’27 commissioned by the Department of Health, PwC highlighted, “the use of technology and information, if fully implemented, could deliver significant benefits to the NHS and its service users. These benefits could be a mix of financial and non-financial benefits, including improvements to quality and efficiency as well as patient experience and satisfaction.” Among the priority actions identified was the need to capture person- based information at the point of care to maximise the usability and value of the information in the patient care context

One problem, as highlighted in Peter Dunwell’s article, has been the past experience of technology in GP practices, which has not always been positive, leaving GPs with a less than wholehearted enthusiasm for new systems. However, speech recognition is not a technology specific to healthcare but rather a commercial technology in which healthcare specific variants are available. Practice Index30 suggests, “A digital dictation system can greatly improve the efficiency of doctors’ note taking and recording. The software is extremely clever in learning and recognising words, including detailed medical terminology.”

Speech Recognition: Supporting the GP and Supporting the Patient Also in 2013, IT Pro28 suggested that “The use of speech recognition tools could revolutionise the NHS, but departments are slow to adopt.” The article included a comment from Dr Ivan Camphor, a senior partner at the Heatherlands Medical Centre on Merseyside, that, “speech recognition software has transformed the way [his] GP surgery operates over the past two years, especially when it comes to writing up appointment notes.” As well as the time and labour saving value of speech recognition, he also cited the value for the patient in being present when the notes are being taken contemporaneously as the consultation progresses and, writing this time in Medeconomics 29 about the business of general practice, he explains, “An immediate benefit to patients is that the verbatim capture of information encourages more data and detail to be added to a report or letter in real-time during the consultation. The more detailed and accurate the letter or report is, the sooner the patient can receive not only the next level of treatment, but also the right treatment.”

Better Use of People and Their Time As well as the direct benefits of accuracy, speed, completeness of records, better patient involvement and immediacy, using a speech recognition system will also improve staff flexibility. So when, say, a practice secretary is absent, rather than either work not being done or incurring the additional cost of overtime and/or temporary staff, practice managers can better prioritise because the key tasks of patient record updating, letter writing and referrals will all be carried out by the speech recognition system. Additionally, the quality of records and all documentation is consistent because it does not rely on the clinician’s typing skills – or the ‘fatness’ of their two typing fingers. And, while the ability to take notes with the patient there is valued, it is also possible for doctors to add notes of a more technical nature, or that have been researched, at a time convenient to their workload. The secretarial staff might well still format the overall patient notes but as users become increasingly familiar with the system they are using, even that will change. With routine tasks automated in this way, it will be possible to assign staff to more interesting work which will, in turn, improve job satisfaction for a better, happier working environment. WWW.PRIMARYCAREREPORTS.CO.UK | 13


The use of technology and information, if fully implemented, could deliver significant benefits to the NHS and its service users. These benefits could be a mix of financial and non-financial benefits, including improvements to quality and efficiency as well as patient experience and satisfaction


Continuing with this theme, Nuance31 has unearthed some interesting statistics and findings from independent research, including that clinicians spend over 50% of their time on clinical documentation processes. The research offered insights on, “the impact of clinical documentation on the clinician, patient flow and process factors to point to the wider economic implications for health trusts at a time when many are on the cusp of making significant technology investments in electronic health records (EHR).” The research also revealed that £20,000 a year is spent in terms of time/value by a doctor searching for information. Put simply, when doctors are occupied with administrative and routine tasks, they can’t be seeing and treating patients. That wastes time and wasted time costs money.

Indirect to Direct Inputs We are at one of those times when a fundamental characteristic of technology is changing. This can best described as moving from indirect to direct inputs. For a good summation of the phenomenon in medical practice, readers might like to look at the US National Library of Medicine publication ‘Using Direct and Indirect Input Devices: Attention Demands and Age-Related Differences’32. It chronicles the shift from keyboard, mouse, joystick… (indirect inputs) to touch screens, light pens and voice recognition… (direct inputs). Technology has enabled a far more natural relationship between people and their IT systems which will, in turn, make IT use a better experience.


Key Factors When Selecting Speech Recognition Software Obviously, potential users will want to compare systems but there will be some key factors that they’ll need to consider. Can the new software be compatible with other software in the practice? The software provider can usually answer that question. Will the new system be easy to use? There will always have to be some training for a new system but its use should rapidly become as natural as… speaking. Can the software be platform agnostic; i.e. can users enjoy the same benefits whether sitting in front of their PC or using a smartphone? Does the system offer digital signatures – a big time saver in any practice? And finally, work with the software supplier to make sure that a period is allocated for implementation.


References: 1 PC World



B.H. Juang & Lawrence R. Rabiner


How Stuff Works


Speech Empowered Computing



Self Publishing Advice Center


Military Systems and Technology


NHS Choices


Citizens Advice


NHS Health Careers


NHS England, General Practice Forward View


GP notebook


Pages 6, 8, 9, 13-15, 153, 160, 199




1st Providers Choice


Talking Point


First Practice Management


The King’s Fund

and 19

NHS England


National Health Executive




Health Careers


General Medical Council


Medical Protection


NICE & NHS Professionals


The King’s Fund 27

PWC for Department of Health


IT Pro




Practice Index




NCBI US National Library of Medicine WWW.PRIMARYCAREREPORTS.CO.UK | 15




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