Dragon Dictation Introduction

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1 Dragon Dictation Introduction Nuance s Dragon Medical One is a voice recognition program that allows you to dictate into many areas of the Unity EHR. Here are some tips on using Dragon. INTRODUCTION By and large, Dragon can be used to dictate most anywhere that you can type. The most common opportunities are within documents themselves (clinical notes, letters, etc.), or on mpage fields where typed entry is utilized. In clinical notes, the places where Dragon is most useful are the places where you enter unique text for each patient, such as the Present Illness or in the Plan section of the note the places where you need to tell a story. On the other hand, when making brief entries, like completing a surgical history or problem list, you ll probably find it easier to just type a few words. Similarly, navigating within a document with your mouse may be simpler than trying to navigate by voice. You ll soon find a workflow that utilizes a combination of typing and talking that is most efficient for you. Accuracy is stated to be as high as 95%, but you still need to proofread what you ve dictated, since there will always be some errors. As a rule of thumb, medical terminology spoken as a block of text is very accurate. Brief monosyllable phrases of normal English, especially without surrounding context, are more challenging for the program. Error correction will be discussed later in this document. MICROPHONE There are a few ways to dictate using Dragon. One is to use a physical microphone, such as the Nuance PowerMic. Another is to use the microphone built into a Windows tablet device like the Surface Pro. Attendings can also use a smartphone app called PowerMic Mobile. Nuance PowerMics will be deployed at several computers in our facilities, especially in the hospitals. These microphones are paired with those computers, so they can only be used at these workstations. It is important NOT to try to move them to other locations. The PowerMic Mobile app can be downloaded for free from your smartphone s app store. Most attendings will be licensed to use this application near Go Live or upon beginning work at USA. Many will prefer to use this approach, since it allows you to dictate at any workstation, laptop, or tablet device you may be using at the time. This will have only trivial impact on your phone plan s data usage (zero impact when you re on WiFi). At Favorites Fair or training you ll be assisted with initial setup, which will include following these links on your smartphone: iphone: dmic://config_?nmstoken=mzm0otk1nzctrdkzos00mzfdlui4rkqtmdg0m0i4meq5ndzg

2 Android: When it comes to the basics of dictating, these are more similar than different. The main thing you ll do with all of them is turn the microphone on and off. PowerMic Mobile gives you most of the functionality of the physical PowerMic on your smartphone. Some limited navigation and command functions are available with either, though you can also perform these with the mouse or voice commands. GETTING STARTED Whichever microphone you use, you ll begin by logging in to the Unity domain. You ll see the usual Unity applications (PowerChart, FirstNet, etc.), and a Dragon application called Unity Nuance Dragon. You can log on to your chosen Unity application, then log on to Unity Nuance Dragon. Using PowerChart as an example, that would be the two applications highlighted in green here: For PowerChart users there is another icon, Unity Nuance Dragon PowerChart, highlighted in red above. Starting it is the same as opening both PowerChart and Unity Nuance Dragon separately. It doesn t matter whether you log in to Unity or Dragon first. Log in to Unity using your credentials as usual. The Dragon logon screen will look like this:

3 The only thing you may have to change here is the Microphone. But basically you just have to click OK. Physical Nuance PowerMic Users: When you use the USA Nuance Dragon PowerChart link to log on at a computer with a Nuance PowerMic attached, the microphone will be preselected to Microphone (PowerMicII- NS): In fact, you may see this screen only transiently, if at all; after logging in to PowerChart it ll know the microphone is attached, and you re ready to dictate. If you ever log out of Dragon and need to manually log back on, you can select the PowerMicII-NS option if necessary.

4 Tablet Users: When you use the USA Nuance Dragon PowerChart link to log on to a Windows tablet device, you may need to select the onboard microphone if you wish to dictate using that. The exact microphone name will vary depending upon the device, but it will look something like this example from a Surface Pro: After making this selection click OK. Dragon will start, and you ll be able to dictate into Unity. ipad users will need to use the PowerMic Mobile approach, which follows. PowerMic Mobile Users: When you use the USA Nuance Dragon PowerChart link to log onto a computer without a physical PowerMic attached, the Microphone will be set to Nuance PowerMic Mobile, though you can manually select it if that ever becomes necessary:

5 Then click OK. You ll next see the pairing window, which is used to connect to your smartphone: If the PowerMic Mobile app on your smartphone is already running, you may only see this transiently. On your smartphone, open the PowerMic Mobile app. Enter your user name if not done previously, then tap Log In:

6 In a few seconds you ll be paired with the device running Unity, and the pairing window will disappear. You re now ready to dictate. If the pairing ever doesn t happen automatically, you ll be given the opportunity to manually enter the Pairing ID shown in the pairing window. Any time you close the PowerMic Mobile app, or your phone powers off, the pairing window will reappear. You can minimize it to get it out of the way. As soon as you turn your phone back on within that work session, pairing will automatically resume. This way you can work through your clinic session, only turning your phone on when you re dictating. DRAGON OPTIONS The first time you use Dragon, there are a few options you may wish to change from the defaults. On the Dragon Toolbar, click Options: Go to Dictation Box. It may initially look like this:

7 You may wish to select Transfer text when recording is stopped, as well as Keep text on the Clipboard after transferring: When Dragon does its initial transcription, it does it to a Dragon text box. Selecting Transfer text when recording is stopped will transfer that text to the selected Unity field without making you do it manually. Keep text on the Clipboard after transferring allows you to manually paste that text somewhere in case the automatic transfer fails for some reason. You also want to look at the Microphone Buttons options. Initially, some of the buttons may not be configured at all, or not configured ideally. When you re using the physical Nuance PowerMic, you may initially see these button selections:

8 Recommended settings, which make use of the intended function of the buttons, are:

9 Additionally, you may wish to select the behavior of the Microphone button. Press-and-hold requires you to hold the button down to speak; Microphone On/Off toggles it on and off. You have similar selections for PowerMic Mobile, where the Previous Field and Next Field buttons may not be configured out of the box. Recommended settings are:

10 When done, click Apply All, then Close. You will probably have to do this only once. (If you use both PowerMic Mobile and the physical PowerMic, you ll have to do it for each.) MICROPHONE STATUS INDICATOR The Dragon toolbar indicates whether your microphone is on or off, but it may not mean what you intuitively think. The vast majority of hardware and software recorders use RED to indicate the mic is ON. Dragon is the opposite. Think of it like a traffic light: Red = stop, Green = Go. Microphone off: Microphone on:

11 VOICE COMMANDS There are a number of voice commands you can use in Dragon to perform navigation, correction, and other functions. You ll probably quickly learn the handful that you find useful. But sometimes you may find it easier to skip the voice commands, and just use buttons on the microphone and/or the mouse. You can see a list of the available voice command by saying What can I say or selecting What You Can Say on the Dragon Toolbar: leading to:

12 AUTO-TEXT You can create and use Auto-Text in Dragon, but the first thing to know is that these are distinct from the Auto-Texts you ve created in Unity. You invoke Auto-Text in Unity by typing a shortcut; you invoke Auto-Text in Unity with a voice command. You ll want to consider the setting in which you ll use your Auto-Text. At some spots in a document, it may be easiest to type a shortcut to insert the Auto-Text, then just type a couple words you need to change. The Review of Systems section might be an example of this. For those, create Auto-Text within Unity. At other spots you might wish to verbally insert a block of text. An example might be when you re giving standard instructions while dictating the Plan section of a note say the usual instructions you give a migraine patient when starting a triptan for the first time. For those you might prefer creating the Auto-Text in Dragon. And there s no reason you can t do both; after creating it in one place, you can copy and paste it to the other. To create Auto-Text in Dragon, select Manage Auto-texts from the Dragon Toolbar:

13 If you ve already typed or dictated something you d like to make an Auto-Text, you can select it: then say Make that an Auto-Text. The Manage Auto-Text window will appear: Type a Name and Spoken form. Initially the Spoken form will be the same as the name, but if the name is long you may wish to shorten the spoken form. You can add a description as well, though that is optional:

14 Edit the Content as necessary. This is also where you could paste your text if you ve copied it from a document or from a Unity Auto-Text you ve previously created. When done, click Apply All, then Close. To use this in the future, you would put the cursor in the desired location in the note and say Insert nail removal plan. The text will appear. If you wish to have standard entries in a Dragon Auto-Text, put brackets around those entries. For example, you could create a typical adult negative review of systems that might look like this: Constitutional: [No fever]. ENMT: [No nasal drainage or sore throat]. Respiratory: [No cough or dyspnea]. Cardiovascular: [No chest pain, palpitations, or edema]. GI: [No abdominal pain, diarrhea, nausea, or vomiting]. GU: [No dysuria]. Neuro: [No dizziness, headache, or focal weakness]. Integumentary: [No pruritus or rash]. Musculoskeletal: [No joint pain or neck/back pain]. Hema/Lymph: [No lymphadenopathy].

15 You could use the mouse, microphone buttons, or Dragon navigation commands like Next field to move among the bracketed fields. Dictate any changes necessary. When done you would use the microphone button or verbal command to Accept defaults to remove the brackets. Those standard entries can also be empty brackets, allowing you to create a fill-in-the-blank Auto-Text, e.g., like this: Estimated blood loss [] ml. Using your navigation method of choice you would move to the field then speak the entry. This works particularly well when you have a number of such entries to make in a row. ERROR CORRECTION You ll probably take a multi-pronged approach to correcting transcription errors. Things like the presence or absence of ed at the end of a word are just very challenging for the program. It s not uncommon to dictate something like: It may develop gradually and have it transcribed as It may developed gradually. Speaking very deliberately can help, but some degree of errors like this are probably inevitable. As you proofread your note, the simplest and fastest thing may just be to delete the ed and move on. Other errors are a little bigger. For example, after dictating This bird is a parrot Dragon typed things like This Byrd is apparent or This Byrd is a parent. This is an example where the program is good with medical terminology, but weaker with regular English. Upon seeing such an error, one correction option is to say Correct that, which brings up some alternatives:

16 If the correct alternative is listed, you can say something like choose one to insert the correct choice. However, in this case, none of the alternatives are correct. While you can always just type a correction and move on, when you have problems with words or phrases that you use frequently, you probably want to try to get Dragon to transcribe them correctly. On the Dragon toolbar, select Manage Vocabulary: When Manage Vocabulary comes up, you ll see a list of words you ve previously addressed, as well as the opportunity to add more. Click Add:

17 to bring up the Manage Vocabulary window: Type the problematic word: You might consider doing all the words that were confused, like parrot, parent, and apparent. You have three options here. One is to click Use Default Pronunciation. This actually works pretty well. It s as if Dragon actually knows how to pronounce everything, but it just didn t

18 think you were likely to say the word parrot. It ll either add the entry or confirm that it s already in the vocabulary. This alone improves your accuracy the next time. But if you keep having problems, the second option is to click the onscreen microphone. It will instruct you to pronounce the word: After you ve said the word, it will ask you to click Confirm: It will then tell you the word has been successfully trained: Note that a strategy here might be to NOT pronounce the word correctly, but pronounce it in an exaggerated way that makes it stand out. This works well with unusual or non-english proper nouns. The third option is to type out a phonetic pronunciation. To do that, click Enter the word as you would pronounce it:

19 Type the phonetic spelling, then click Save. As the onscreen suggestion advises, this is a good option when the word is pronounced dramatically different from the way it appears: The entry will be confirmed:

20 When you go back to Manage Vocabulary, you ll see the words you ve added: Even after all that, it still may not get the transcription right. At that point, if it s a phrase you use commonly, you can train the whole phrase. For this admittedly artificial example, we ll click the microphone to train the phrase this bird is a parrot:

21 After speaking and confirming, the phrase will be added to your vocabulary: Going forward it still may not always get it right, but going through this process for a couple months with your most common problem words and phrases will generally improve your accuracy.

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