Medical Dictation
January 14, 2022

Ultimate Guide to Medical Dictation

Ultimate Guide to Medical Dictation

Medical dictation is a great asset to healthcare businesses, and with its services, you can elevate the quality of your practice and effectively prioritize patient needs. However, we recognize that there are a multitude of factors that go into its services, and at first glance, it can be overwhelming. From security, to voice recognition technology, to the future of medical dictation as a whole, there are a lot of bases to cover. As a result, we’ve compiled all the essentials when it comes to medical dictation, in the hopes of answering any and all questions that you may have! 

The Basics

What is medical dictation?

Although it may seem obvious, it’s good to define and clarify what medical dictation is. Medical speech recognition often refers to the use of computer software to translate speech into text and is an increasingly common healthcare practice to document information. Using advanced technology, all you have to do is speak into the software, and it easily picks up each word you say, and transcribes it electronically at lightning speed. With its services, you can easily capture all client details and information, meaning your medical billing and coding practices and resulting reimbursements can be more accurate. No longer do you have to manually transcribe, as voice recognition technology works to note all your information with the correct medical terminology, spelling, and grammar. You can ensure your notes are high-quality, and accurately represent the patient experience, with reduced chances of misinterpretation, and more time for you to focus on doing what you do best; treating patients.

The technology  

Medical dictation software is an incredibly intuitive technology, and while every technology has its small differences, most medical speech recognition software incorporates similar programs. With the software, phrases, sentences, and words can be easily picked up with a connected medical terminology database, and the system can automatically check for any spelling and grammar errors. Normally, the speech recognition algorithm is designed with iterative learning in mind, meaning that as time goes on, the technology will recognize clinical note structures and terms within the medical context, and correct more errors with increased experience. This makes for highly effective notes that are rich with clinical insight, altogether contributing towards better medical outcomes and treatment. 

The technological process of converting sound into text in a transmissible format, is as follows:

  1. Analog-to-digital converter translates sound waves from your speech into data that computers can use.
  2. The data is broken down into small matching phonemes with known phrases and words
  3. The software analyzes the phonemes in comparison to the known sentences, phrases, and words
  4. Once the software has finished the analysis, the software infers speech from the words and translates it into text that is used by healthcare practitioners. 

Note: It’s important to note that this software commonly uses Artificial Intelligence (AI). AI uses intelligence controlled by computer technology and systems to conduct tasks, and uses advanced learning systems that support learning from experience. AI can accommodate and adjust with the introduction of new inputs and stimuli, and with its ability to process large amounts of data and easily identify patterns, there are endless possibilities to what AI can do. It can alleviate repetitive tasks, such as manually composing clinical documents and notes. 

Medical dictation problems

Compatible Devices

You may be curious as to what devices can support medical dictation software, and the answer to that is simple. Most devices can support voice-to-text transcription, so long as there is a high-quality microphone embedded into the hardware of the device, and that there are working speakers that allow for high-quality playback. To clarify, any of the following devices can be used for medical dictation services:

  • Computers
  • Laptops
  • Tablets
  • Mobile devices
  • Handheld digital recorders

Types of speech recognition software 

There are two main speech recognition tools to use within the clinical context, with the first using dictation that transcribes your speech word-for-word, and the other using AI transcription that applies NLP. NLP is natural language processing that identifies relevant medical terms and phrases, and filters out the filler information. For example, it often removes the fluffy language, such as the ‘um's’ and ‘uhs’, as well as the small talk, which makes for a much more efficient way to format clinical notes. You don’t have to spend as much time on the reviewing, proofreading, and editing process, which is always a plus!

When it comes to the two specific classes of speech recognition software, it comes down to the following two options, which can be used as two distinct features, or together:

  1. Back-end speech recognition - This speech software notes the words you speak, records them digitally, and then is translated into text. This method is more of a timely approach, and means that medical dictation is more of a process, with time needing to be reserved to edit. Once you’ve spoken, the software sends a draft document with the voice recording for review by a medical transcriptionist or practitioner. While you do need to manually review information, many healthcare professionals prefer this software due to its reliability. Because you have to evaluate and assess the content for mistakes, you can ensure that the final product is logical, legible, and easy to follow. 
  2. Front-end speech recognition - Through this route, spoken words are instantly translated into text, meaning that you don’t need to spend as much time on the transcription process. This is extremely cost-effective, as you don’t need to hire medical transcriptionists, however, you may be required to fixi grammar or words that the software incorrectly heard. For this reason, many healthcare professionals prefer front-end speech recognition for personal notes that aren’t included in medical or electronic health records. Ideally, this is for drafting short medical reports, so you don’t have to edit as frequently. 
Typing healthcare progress notes

Scope of medical dictation 

Medical dictation software can be used by any healthcare professional, regardless of their discipline, and it is not exclusive to a particular group. Medical dictation can elevate the quality of any workplace, including for those in the following areas of health:

  • Physical therapy
  • Mental health
  • Psychology
  • Psychiatry
  • Nurses
  • Doctors
  • Acupuncturists
  • Physiotherapists
  • Dentists
  • Occupational therapists
  • Clinical social workers

As well as any other area concerning health! Medical dictation can accommodate and adjust to any discipline, and if connected with the relevant specialized medical terminology library, you’ll be able to accurately record medical conditions and provide valuable care. The system will be able to recognize common symptoms in alignment with their relevant area of health, meaning that you can produce higher coordination of care and higher clinical outcomes. Regardless of your discipline, you should consider implementing medical dictation services to boost growth and productivity, as it has benefits that all healthcare practitioners can reap. 

Manual vs. Electronic Transcription

A brief history of dictation services

Before medical dictation services, many electronic records and medical documents were conducted manually, and often involved medical transcriptionists to fill the role. This meant entering information under fields, and checkboxes, with dedicated staff needing to follow up on each patient document. This method is very time-consuming, let alone the older route of doing things with pen and paper! Practitioners don’t want to spend time typing on their computers when they could be treating patients in need. They also don’t want to waste business costs by outsourcing employees who have the specific capability of being able to transcribe, as this can drain funds unnecessarily, when electronic dictation provides a viable route to overcome these options. Electronic medical dictation alleviates most business costs and strains, and is now considered standard when it comes to dictating medical information, and presenting patient conditions.  

Progress note typing

Pros vs. cons of typing and dictated notes 

It’s important that you look at the pros and cons of each method before investing temporal and financial resources into one delivery route, as you need to ensure that it can meet your business and patient needs. Using typed notes versus using dictated can provide distinct benefits, and although medical dictation is the newest technology, it’s not for everyone. You must choose based on what best suits you, and what can elevate your current business practices and procedures. To help you, we have summarized the essentials into a comparison for your convenience. 

Typed

  • Pro: Typing can save you a significant amount of time as opposed to handwritten notes, and is still a highly effective way of producing clinical documents. It is much faster than pen and paper, and if the right employees are hired with sufficient technical typing skills, this can be especially beneficial.
  • Pro: When you type notes, you have greater control over the editing and review process, as you can assess content as you write. This means that while it may take more time, the final product is less likely to contain spelling, grammatical, and syntax errors, with the correct use of medical terminology. 
  • Con: Typing requires a certain level of skill to be able to type quickly and accurately. This will continue to develop as employees gain more experience with medical notes, however, this process may take time.
  • Con: This may be a more costly method depending on the resources you have, as you may need to outsource a transcriptionist or typist to produce the clinical documents and notes. Practitioners don’t want to have to spend time typing notes when the time could be taken to care for patients, and support effective treatments. 
Typing notes is the worst

Dictation

  • Pro: Producing notes and documents via medical dictation services is one of the most effective ways to relay patient information. In a Stanford study, medical dictation was proven to be almost three times faster than typing, which is excellent for healthcare professionals. With dictation services, practitioners can focus more on serving patients and caring for their needs. 
  • Pro: Dictated notes are just as accurate as typed, for the most part. With advanced intelligence systems, medical dictation services can pick up on the right terminology, and can easily recognize words and phrases that you mention. In some ways, it’s almost too good, as medical dictation can pick up ‘ums’, ‘uhs’, and everything in between! 
  • Pro: With medical dictation services, you don’t need to hire specialized individuals to use the software. Anyone can use it, regardless of their background or technical skill, which makes for a great asset to implement within your healthcare practice.  
  • Con: While it is faster to create the documents with dictation services, more time may need to be spent on the reviewing process. Despite what they may seem, machines aren’t perfect, and can still produce mistakes that only the human eye can detect and pick up. Back-end software prolongs this process, however, dictation services that incorporate front-end software services allow mistakes to be fixed immediately. As a result, front-end software services may be able to better minimize the time spent on the reviewing process. 

Medical Transcription

The medical transcription process

To put it into perspective, it may be easier to understand medical dictation services within the context of medical transcription as a whole. Examining the entire medical transcription service can help simplify things, and help you take notes to not only benefit your own knowledge, but so you can tailor your business processes to the standardized transcription process.

  1. Dictating - The very first step of the transcription process is dictating medical information to a medical transcription device. The healthcare professional should record patient information and data through a compatible device or platform that enables the health information to be stored. Devices include phones, computers, laptops, tablets, handheld digital recorders, as well as any other hardware that contains recording functions. You must ensure that the device supports high-quality audio, and that you enunciate clearly so all terms and phrases can be picked up and recognized. 
  2. Transmitting - The second step is to transmit the video and/or audio files once they’ve been recorded. To ensure high security, it’s also best that these files are securely stored on encrypted cloud servers, where there is a significantly reduced risk of file corruption and data leakage. Especially considering these files contain specific information exclusive to particular patients with confidential details, it is extremely important that they are protected. 
  3. Transcribing - Transcriptionists or medical professionals will then need to listen to the audio recordings, and type what they hear to translate speech to text. This is often a lengthy process, and may require frequent rewinding to understand what is being said, and that all relevant information is noted with filler words removed. If there are background noises or other sound contaminations within the recording, this transcription process may take additional time for the recordings to be analyzed. If sections are missing, or some information isn’t clear, then extra time must be taken to re-record the patient information in a way that is clarifiable. 
  4. Editing - Once the medical information has been typed, it’s important to review the text for any mistakes. The patient data needs to be edited, assessed, and proofread to ensure that all medical terminology is correctly used, that the structure and syntax are easily understandable by those who read it, and that there is an overall high accuracy concerning spelling and grammar. With dictation, error rates are as low as 5%, which is excellent for saving time and supporting medical professionals to spend time treating patients. It’s important to note that the editing process for front-end dictation software is slightly faster due to the ability to make real-time corrections, which is also highly advantageous. 
  5. Sending - For the final step of the medical transcription process, the files need to be sent to authorized individuals within medical practices. These files should be transferred over secure platforms that actively work to minimize file corruption and loss, and ideally, are transferred within encrypted cloud servers. This way, you can ensure that the patient information is held confidential and private and that the files are sent as quickly as possible so medical practitioners can properly utilize the information. Smooth transaction operations allow healthcare professionals to incorporate their notes into effective treatment plans for patients. 
medical dictation process graphic


Advantages of Medical Dictation

The benefits of medical dictation services 

There are a multitude of benefits that come with medical dictation services, and it’s important that you recognize them so you can consider implementing their use within your own healthcare services. With medical dictation, you can greatly enhance your current business processes, and elevate the quality of your practice in providing greater support to clients and staff. Using medical transcription will see a boost in growth and productivity within your workplace, and can help you gain a competitive advantage over other healthcare practices, as well as work towards more effective treatment for your clients. Some of medical dictation services’ top features include the following:

  • High-quality care - With medical dictation services, you can efficiently organize patient information and properly represent patient conditions with accurate information. Symptoms are easier to pinpoint, which makes for more effective treatment, and increased coordination and continuity of care amongst patients. 
  • Privacy - Medical dictation can allow for patient privacy and confidentiality when it comes to their medical information, as it means you manually eliminate any unnecessary information. You can safely store edited and unedited versions online and within cloud storage, ensuring that private information is at minimal risk of jeopardization. Arguably, medical dictated documents can be more easily protected from hackers and data leaks with highly encrypted servers, as opposed to pen and paper documents that are frequently lost. 
  • Time-efficiency - The healthcare industry is often overwhelmed with a large workload, with patients being referred left and right, and schedules being frequently changed and interrupted. It can be an unpredictable environment, and so any opportunity to free up time is always a welcome one. Medical dictation services provide an excellent way for healthcare practitioners to cut down on time, as the speech recognition software automates the entire transcription process, meaning you don’t have to spend copious hours typing out information. Not only this, but having more accurate notes allows for improved medical billing and coding processes, which contributes towards cheaper administrative and security costs!
  • Alleviated language barriers - Medical dictation software isn’t exclusive to a particular language, and can work as a multi-translation function. The services can also pick up words despite any accents you or your staff may have, which makes for an excellent universal tool for healthcare businesses.
  • Broad variability - You don’t need to own a specific device to be able to use medical dictation services, and you can use most electronic hardware to record speech and translate it into text. Computers, phones, and tablets, are all great mediums to use, and depending on the applications you install, there are a variety of features you can access in relation to medical dictation. 
  • Cost-efficiency - Depending on the medical dictation software you use, you can actually cut substantial costs for your practice. Not every tool you incorporate needs to be expensive and put a damper on your budget, rather, you can easily transcribe medical information with minimal costs. There is a plethora of transcription software out there, and many are sure to appeal to your practice, regardless of how large or small your budget may be. 
  • Wide scope - Medical dictation services aren’t exclusive to any particular area of health or healthcare professional, which is great! Anyone can benefit from their services, without fear that the software isn’t tailorable to their business needs. 
  • Simplicity - Most speech-to-text transcription services are super easy to use, regardless of your technical skill when it comes to technology and online software. All you should have to do is click a ‘start’ option, and you’re on your way! As a result, medical dictation tools are a highly accessible and transferable option for healthcare businesses to integrate within their operations, as minimal training and education are needed on their use. 
  • Higher accuracy - With artificial intelligence guiding most of the dictation processes, the software can transcribe in real-time, which means more words, terms, and phrases can be picked up. Rarely are any critical medical details missed, and you can significantly reduce errors when it comes to terminology use, spelling, grammar, syntax, and punctuation. As a result, you can more accurately represent the patient experience with all symptoms noted, leading to a more accurate diagnosis. Using medical dictation services can increase the efficacy of your treatments, and provide greater clinical outcomes!
  • Stronger connections - As a flow-on effect, because of a more representative patient experience, you can work towards strengthening and building professional relationships amongst your clients. Supporting patients by allowing them to feel understood within the medical workspace is a great way to enhance the quality of your practice, and know you’re making a difference. 

Medical Dictation and HIPAA

What is HIPAA

The Health Insurance Portability and Accountability Act, more commonly known as HIPAA, is a frequent buzzword within the healthcare workspace. It is a legal requirement that ensures that businesses are held accountable for their actions, and have levels of responsibility attributed to their health actions and procedures. HIPAA outlines the universal standards that businesses must comply with in order to fulfill legal obligations, but also to protect and secure patient information, which is especially important with healthcare. 

The healthcare industry deals with highly sensitive medical information, and so it is vital that only authorized users have access to data - and medical dictation is no exception. For healthcare practices to operate legally and on ethical grounds, they must comply with HIPAA security protocol to minimize the risk of data breaches, data loss, leakages, hacking, and other situations where information may be jeopardized. In the case that this does occur, HIPAA regulations serve to outline the financial penalties and fines for failing to adhere to their standards, which are important so businesses are aware of the consequences that may follow suspicious activity. 

Notes

  • The term PHI often comes up when discussing HIPAA, and all you need to know is that it stands for protected health information, and concerns a patient’s medical record with unique identifying diagnosis and treatment information. This is also in addition to personal contact information, such as name, phone, physical and email address, and social security numbers. PHI is inherently linked to medical dictation services, as it is often integrated within clinical documents and notes. 
  • The AAMT guidelines, or the American Association for Medical Transcription services, is the official organization that establishes regulations that are specific to medical dictation and transcription services. While HIPAA is the overarching institution that sets security protocols regarding the protection of client data and maintaining privacy, the AAMT helps support healthcare practices to abide by privacy practices. 
HIPAA Graphic


HIPAA medical dictation security features

With medical dictation services, there are a variety of security features implemented within the software to ensure that you are complying with legal requirements, even when it comes to transcribing information. The software that you choose to run your business operations on must be in accordance with HIPAA regulations, and failing to comply could result in expensive repercussions for you and your business. To optimize your resources, and ensure that you use medical dictation safely and securely, it is important that your software incorporates the following features. 

  • Encrypted storage - All audio files containing patient information should be stored with the minimum encryption AES-256 level, as outlined by HIPAA guidelines, as this ensures that all medical information is contained on a highly secure server. Clinical documents and notes will be at minimal risk of hacking and data leakages from external parties, and you can have full confidence in knowing that you have the necessary precautions in place to safeguard information. 
  • Encrypted transfers - Not only do you need to encrypt the storage of audio files, but you also need encryption in place when it comes to the transmission of medical data. Within the healthcare space, patients are often referred across clinics and practices, and there may be times when you need to confer and consult with fellow healthcare practitioners. As a result, you need to be able to easily transfer information in a way that is secure to avoid data loss. This may mean using methods such as the Secure Sockets Layer (SSL), as standard FTP email and file transfers aren’t secure enough to handle the transfer. You must be able to efficiently upload records to cloud systems through AES-256 protected channels so you can be assured that patient data is protected. 
  • Password protection - As well as following strong password guidelines, such as using upper and lower case characters, numbers and special characters, it’s also important that you have authentication steps to ensure that only authorized users have access to information. Various authentication measures could include biometrics such as retina and fingerprint scans, which all help contribute towards stronger security concerning your medical data. 
  • Remote password lock - In the case that you suspect information is being hacked, you should have the option to lock devices and medical data from wherever you are. Locking devices remotely enables you to take action immediately, and regain possession of your healthcare information from hackers, which is an easy way to prevent cybersecurity situations from escalating further. 
  • Cloud backup - Medical information must be backed up to a remote location and offsite storage, such as ‘the cloud.’ This method is frequently used by almost all businesses, as it dodges the long recovery processes by automatically backing up information as it enters its servers, and provides highly encrypted channels to minimize the risk of hacking. It is time and cost-efficient, proving to be a highly viable option when it comes to storing medical information. 
  • Restricted access - It’s important that only relevant individuals have access to the specific information they need, as this reduces chances of information getting into the wrong hands, and provides easier traceability in the case that information is compromised. Knowing only a few employees have access to medical information makes it easier to track where it’s been and where it’s going, which is ideal so you know where to attribute certain responsibilities.

Software Use

Features you should consider when selecting software

When it comes to choosing medical dictation software, it can often feel overwhelming with the number of options out there, each with their own distinct and unique features. Selecting software is one of the biggest business decisions you’ll make when it comes to establishing and developing healthcare practices, as whatever you choose, you need to ensure that it can enhance and grow your operations. To guide you along this process, we have collated some of the most important features to consider when evaluating your options. 

example of the best medical dictation software


  • Easy installation - Medical dictation software services shouldn’t be difficult to understand when it comes to installation and downloading. It should be highly intuitive and easy to follow, regardless of your technical skill. While it will take some time and effort to implement and master them, you shouldn’t require extensive prior knowledge. 
  • Versatility - The medical dictation software you choose should be compatible with most electronic devices, including computers, mobile phones, laptops, and tablets. There should be great flexibility when it comes to remote working, and having consistency with the same software installed across digital devices should allow for a more optimized workflow. This also means you don’t need to upgrade your devices or waste financial resources unnecessarily on buying technology that accommodates your software. 
  • High integration - You need to ensure that the software is able to be smoothly integrated with your existing databases, online electronic health records, and work in coalition with all other business processes concerning your practice. This also increases productivity and convenience, with information being able to be easily transferred, and can be imported into your software services. Doing this will save you an immense amount of time and effort, leaving you room to do what you do best; care for your patients’ needs. 
  • HIPAA compliance - Perhaps the most important of all, you need to make sure that your software service fulfills legal obligations, and is able to support patients' privacy by protecting their data. Failing to do so could result in steep fines and penalties that not only cost your business thousands but can also damage your reputation. It is a difficult process to rebuild and strengthen professional relationships with your clients, depending on the offense, and so it’s best to choose software that clearly outlines the steps taken to combat HIPAA violations and data leaks. 

Do’s and don’ts with medical dictation software

While it’s one thing to select software, the quality of it is largely dependent on how you use its services. It’s important that you are informed of good practices, so you can effectively incorporate medical dictation within your practice, and maximize the features that it offers to your fullest potential. Because of the time, effort, and finances spent on installing and implementing medical dictation software services, you need to make sure that you consider the following tips:

Do’s

  • Find a quiet space - It’s important that background noise doesn’t contaminate audio recordings, as to allow the medical dictation tool to clearly pick up on terms, phrases, and sentences that you speak. Having incoherent noises can negatively affect your notes, and delay the reviewing and editing process with more time having to be spent on deciphering what is being said.  
  • Enunciate clearly - You must take care to be very clear with each word and phrase you say, as the medical dictation software needs to be able to decode and match your speech. While the machines contain highly advanced intelligence systems, they are still prone to errors, and speaking clearly will aid in clarification to produce highly accurate clinical documents and notes. 
  • Remember to pause - To improve the structure of your notes, pause between sentences. This way, the speech recognition software technology can identify where full stops go, depending on the natural flow and tone of your voice and where you stop. Try not to pause between words, as the software may mistake it as new sentences, which doesn’t make grammatical sense. In that case, you’ll have to spend more time on the review process, so it’s best to emphasize natural pauses between points. 
  • Watch the screen - While you’re speaking, and observing the software dictating your phrases, it’s important that you keep looking at the screen so you can pause when necessary. If you notice a mistake, you can quickly pause the software, identify the mistake, correct it, and then resume. This saves immense time within the reviewing process, as you’ve proofread as you’ve gone. 
  • Maintain consistency - There is a certain art to dictating, and it may take a bit to perfect it, but once you have, you can ensure top-quality clinical notes. When speaking, you should have an even tone, volume, and speed within your voice so the software can easily pick up on the terminology used. Too intense variation can cause distortion within the software, which may result in nonsensical language recorded. As a result, it’s best to approach medical dictation tools with increased awareness of what you say. 
Medical dictation do's

Don’ts

  • Don’t rush - Remember to speak at a consistent pace to ensure that the technology can pick up on everything you say. Rushing can mean critical medical information is missed out, which can be detrimental to patient health as incorrect treatments lead to ineffective clinical outcomes. Keep a normal tone, and take note of what the tool is picking up on the screen in front of you in order to avoid gaps in clinical documents. 
  • Don’t worry about grammar - Because medical dictation tools are supported by advanced artificial intelligence systems, they already incorporate spellcheck and grammar functions. This means that you don’t need to concern yourself with the right spelling, punctuation, and syntax, as the software will automatically inject the right information, such as the correct apostrophes, commas, capital letters, and full stops. The software recognizes what you’re trying to say, as well as places it in the right context, so you don’t need to make spelling a priority when you dictate medical information! 
  • Don’t stop completely - While it’s good to take pauses to edit minor or quick mistakes, don’t stop dictating completely. This interrupts the session, and it can be frustrating for the software to have to find a logical place to start, which can disrupt the overall flow and structure of your clinical documents and notes. You can always go and correct errors once you’ve recorded and transcribed the whole process if the system didn’t manage them right. 
  • Don’t forget to note the end - Remember to state at the end of the recording, ‘end of dictation’ so you can officially recognize the conclusion of your notes, and confirm that all relevant medical information is recorded down. This is especially important considering fellow healthcare practitioners and clinicians are likely to review your notes, and for clearer communication, it is best to specify where your notes begin and end. 
  • Don’t eat, chew, or yawn - While this may seem obvious, avoid eating, chewing, or yawning when dictating notes. The software will likely not recognize this, and doing this can distort the recording transcription. 

The Future of Medical Dictation is here

The Future of Medical Dictation is here

The opportunities within medical dictation services

Medical dictation services are being very quickly integrated within healthcare practices, for their ability to cut temporal and financial costs, as well as increase productivity, convenience, growth, and patient satisfaction. Supported by advancing technologies, such as artificial intelligence and machine learning, medical dictation is revolutionizing how clinical notes and documents are produced and reviewed. With error rates as little as 5%, it’s no secret that speech recognition services are expected to grow exponentially. Practitioners can complete their paperwork without lifting a finger, and all at a low cost. Medical dictation services are a great way to stay competitive within the healthcare industry, and you can be awarded with more accurate, timely financial reimbursements, as well as greater clinical outcomes. It’s a win-win for businesses, and is a surefire way to harness success within your practice. 

We recognize that despite our research and collation of evidence concerning medical dictation services, you may still have questions concerning its use and services. As a result, we have compiled some of the following articles for you to delve into for further research if desired. 

Further reading:

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