This entry is part 1 of 3 in the series Charting

“This job would be great if I didn’t have to chart.” Physicians say this all the time. One way to not have to chart (much) is to work with a Federal Disaster Medical Assistance Team (DMAT) team. Although the National Disaster Medical System now has an electronic medical record (EMR) system, it used to just use scribbling on paper charts. And, since you have sovereign immunity against lawsuits, and you aren’t using your charts for billing, charting could be quite minimal. I have personal knowledge of a medical team in the field, after Hurricane Katrina, in a small, isolated town for a several-hour medical clinic; the team used 8.5×11″ paper on a clipboard for charting, and each patient got one line.Scribe

This isn’t feasible for most real-life physician medical charting. We do have to use our charts for billing, and for protection against lawsuits. (“If you didn’t chart it, it wasn’t done.”)

We also are sometimes faced with the demand for charting so that, instead of a narrative string of ASCII text, our charts are a small database of discrete, labeled elements (e.g., Chief Complaint: chest pain. Duration: 1 day.) This latter is known as structured charting, and is eagerly promoted by researchers, who want structured data, and billing companies, who enjoy the resulting ease of assuring compliance with billing and coding rules. Read the rest of this entry



This entry is part 2 of 3 in the series Charting

"Invisible Idiot" Climbing Route

“Out of sight, out of mind.”

Ever heard the one about the early translation program that converted this aphorism into Chinese and then back? It came out as “invisible idiot.” Regardless, “out of sight, out of mind” is a good general psychological principle. In any nuclear power plant control station, air traffic control center, AWACS plane, aircraft cockpit, or any busy and confusing medical setting whether inpatient, outpatient or ED , people need to know what’s going on. It’s called situational awareness, and it is key to avoiding human error. And we need to keep unimportant stuff out of sight, and out of mind, so people can concentrate on what’s important.

But to keep nuclear reactor coolant pumps, aircraft, or patients in people’s minds, we put something in front of them. Even if it’s just a tiny blinking light, a text summary. or an icon of an airplane. That is why there are tracking systems, to which many of the essays on this site are devoted. Read the rest of this entry


Speech Recognition

This entry is part 3 of 3 in the series Charting

In the Beginning: VoiceEM

Back in 1988, Ray Kurzweil came out with speech-recognition software, including something called VoiceEM. It was an emergency medicine physician charting application; there was also VoiceRAD for radiology. These were DOS programs that ran with that typical DOS 80 character x 25 character text screen. In addition to having a medical-specific vocabulary, VoiceEM had another advantage over the retail shrink-wrap Kurzweil Voice: you could access your voice profile (what the program learned about your particular voice, and the new words you had taught it) from any PC on the network. And, as it learned more about your voice, and as you taught it more words, these were saved back to the server, so you could access this updated “profile” from the network when you started up at the beginning of the next shift. VoiceEM alsom allowed electronic signature, saving your charts on the server and sending them through an interface to an electronic medical record (EMR) system.

VoiceEM employed a speech recognition engine developed by Kurzweil and his engineers. It was advanced for the time but crude by today’s standards. It only recognized Kurzweil Voice






The recognizer wasn’t all that good, but if you gave it a choice of just a few words, it could figure out pretty easily what you said. It was even quite good at discriminating between fifty or a hundred words.

To leverage this, Kurzweil added Applied Intelligence. (Applied Intelligence is Artificial Intelligence, only with more engineering and less hype.) They analyzed ED charts, and created templates for the most common presentations.

Let’s take, example, a “chest pain” template. (I’m grossly oversimplifying so it has only a passing acquaintance with the real template, which appears in the screenshot of VoiceEM’s successor Clinical Reporter, but bear with me, it’ll work for an illustration.) Read the rest of this entry