RESUMO
Creating notes in the EHR is one of the most problematic aspects for health professionals. The main challenges are the time spent on this task and the quality of the records. Automatic speech recognition technologies aim to facilitate clinical documentation for users, optimizing their workflow. In our hospital, we internally developed an automatic speech recognition system (ASR) to record progress notes in a mobile EHR. The objective of this article is to describe the pilot study carried out to evaluate the implementation of ASR to record progress notes in a mobile EHR application. As a result, the specialty that used ASR the most was Home Medicine. The lack of access to a computer at the time of care and the need to perform short and fast evolutions were the main reasons for users to use the system.
Assuntos
Documentação , Interface para o Reconhecimento da Fala , Humanos , Projetos Piloto , Pessoal de Saúde , HospitaisRESUMO
Dermatology is one of the medical fields outside the radiology service that uses image acquisition and analysis in its daily medical practice, mostly through digital dermoscopy imaging modality. The acquisition, transfer, and storage of dermatology images has become an important issue to resolve. We aimed to describe our experience in integrating dermoscopic images into PACS using DICOM as a guide for the health informatics and dermatology community. During 2022 we integrated the video dermoscopy equipment through a strategic plan with an 8-step procedure. We used the DICOM standard with Modality Worklist and Storage commitment. Three systems were involved (video dermoscopy software, the EHR, and PACS). We identified critical steps and faced many challenges, such as the lack of a final model of DICOM standard for dermatology images.