Speech recognition: Evaluation,
implementation, and use
Speech recognition can markedly reduce turnaround time. To encourage radiologists to
use this technology, it is critical to recognize and address some of its shortcomings.
David L. Weiss, MD
C
urrently, there are a handful
of ways to create a radiology
report. For decades, the stan-
dard has simply been transcription,
coupled in more recent years with digi-
tal dictation. Another option, structured
reporting, is used by many radiologists
in mammography but is not widespread
in general radiology. This article will
focus on speech recognition, which is
being adopted by more and more radi-
ology departments, in both academic
medical centers and private practice.
One of the purported advantages of
speech recognition is cost savings. In
reality, a speech recognition system
may, at least in part, shift costs rather
than save them. This is because instead
of paying a transcriptionist, a radiologist
spends time editing and typing. How-
ever, without question, improved turn-
around time is an advantage of speech
recognition, as has been documented in
a number of studies.1,2
One of the disadvantages of speech
recognition is a time penalty. A majority
of radiologists report spending more time
creating and finalizing reports using
speech recognition as compared with
conventional dictation, with a resulting
Dr. Weiss is the Clinical Section Head for
Imaging Informatics at Geisinger Health
System, Danville, PA. He is also a mem-
ber of the editorial board of this journal.
24 ■ SUPPLEMENT TO APPLIED RADIOLOGY
decrease in overall radiologist productiv-
ity.3,4 However, the most serious problem
with speech recognition is its potential to
distract the radiologist from viewing
images. If the radiologist’s eyes are on
the dictation screen rather than on
images, the risk of error increases.5
Acceptance of speech recognition by
radiologists has been complicated by a
misalignment of incentives. Radiologists
only indirectly benefit from the advan-
tages of speech recognition. If cost sav-
ings help the department to stay under
budget, radiologists might receive a
bonus, but it will be slow in coming and
will be shared by many others. Similarly,
improved turnaround time will help to
achieve departmental goals, but diagnos-
tic accuracy and productivity are more
important to most radiologists.
On the other hand, the disadvantages
of speech recognition fall directly on
radiologists, as they suffer the potential
for a time penalty, productivity decrease,
and distraction from image viewing.
Administrators and information technol-
ogy staff must pay attention to this mis-
alignment of incentives and find a so-
lution to it if they want radiologists to
adopt speech recognition.
Case studies
The following case studies illustrate
both the success and, in some ways, the
failure of speech recognition.
©
www.appliedradiology.com
Community hospital
The first case study involves Chestnut
Hill Hospital, a small community hospi-
tal in Philadelphia, PA, with a general
radiology practice of 4 to 5 radiologists
reading 100,000 examinations annually.
In 1998, we installed speech recogni-
tion, shortly after hardware and soft-
ware advances made it practical for
radiology use. The next year we in-
stalled a picture archiving and commu-
nications system (PACS) and, in early
2000, we integrated the 2 systems.
All of the radiologists agreed to imple-
ment speech recognition. We discontin-
ued using a transcriptionist after about a
week. What followed was 4 weeks of dif-
ficulty. First, we ordered the wrong
microphones for data entry (ones without
a bar coder). We weren’t proficient in
using the product as it was designed.
Macro techniques were still in their
infancy. The navigation controllers we
use today were not available. And, ini-
tially, there was no integration between
the PACS and speech recognition.
Nonetheless, report turnaround time
decreased from approximately 72 hours
to 20 to 24 hours immediately after im-
plementation of speech recognition
(Figure 1). There was no further signifi-
cant reduction in turnaround time dur-
ing the first 6 months after installation
of the PACS. However, after we stream-
lined workflow to make the best use of
December 2008
 SPEECH RECOGNITION

Table 1. Speech recognition

implementation strategies
Provide users with incentives
Set realistic expectations
Plan for a drop in productivity
Provide training and ongoing
support
Set a deadline for transition
Consider using a hybrid model
Dictate, edit, and sign
Transcriptionist correction
Maximize efficiency

7 pm. This new schedule consisted of the

same total number of work hours, but
resulted in much better turnaround time.

Large medical center

At Geisinger Medical Center, we
have digital dictation and use structured
FIGURE 1. This graph illustrates average report turnaround time at Chestnut Hill Hospital. Turn- reporting for mammography. We in-
around time decreased from approximately 72 hours to 20 to 24 hours immediately after the stalled speech recognition in the third
implementation of speech recognition [SR]. There was no significant reduction in turnaround quarter of 2004, and radiologists were
time during the first 6 months after the installation of a picture archiving and communications
encouraged, rather than given a man-
system (PACS). However, after streamlining of workflow (mature PACS), average turnaround
time dropped to <4 hours. date, to use it. Therefore, at each work-
station we still have both a speech rec-
ognition microphone and software, and
a conventional digital dictation system.
An interesting pattern developed.
After 6 months, half of our radiologists
were using speech recognition 80% to
90% of the time, and the other half were
using it ≤30% of the time (Figure 2). This
was a bit surprising. It is more common to
see a bell-shaped usage curve, with most
of the radiologists accepting speech
recognition, a handful really embracing
it, and a handful really struggling with it.
What happened at Geisinger? We did
get buy-in from the radiologists ini-
tially, but we may have had unrealistic
expectations of accuracy that led to
frustration with the product after imple-
FIGURE 2. This graph depicts radiologist use of speech recognition at Geisinger Medical Center mentation. A training session with a
6 months after installation. Approximately half of the radiologists used speech recognition 80%
to 90% of the time, and the other half used it ≤30% of the time.
trainer who knows the software inside
and out—and software that has become
the PACS, we did see a major drop in distributing hardcopy studies to be read. highly accurate in recognizing that
turnaround time to an average of <4 Several months after installation of PACS trainer’s speech—is far different from a
hours for all studies. we realized that, since PACS produced new user’s initial experience. In addi-
A major change in workflow involved images hour after hour, we could reconfig- tion to problems with the speech engine,
the radiologists’ work schedules. We were ure our work schedule. All but one radiol- we also had some disruption attribut-
accustomed to leaving the hospital at 5 pm ogist began to leave the hospital at 4 pm, able to the PACS and the radiology
each day, when the film library stopped while the on-call radiologist stayed until information system (RIS).

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SPEECH RECOGNITION

A B

C D

FIGURE 3. (A through D) These screens illustrate modification of a macro for a CT scan of the abdomen and pelvis to insert information on an
abdominal aortic aneurysm. The radiologist is able to do all of these text edits verbally.

These were not the real reasons
speech recognition was not widely used
at Geisinger, however. The main prob-
lem was that we did not communicate
a consistent message that the depart-
ment would be adopting this technol-
ogy. We also had no defined endpoint
for eliminating digital dictation and
have continued to support 2 separate
reporting systems.
Ensuring success
Table 1 outlines some of the steps that
can be taken to ensure adoption of speech
recognition. First, provide meaningful
incentives to users. The incentives could
include bonuses, extra time off, or a re-
duction in productivity requirements for
radiologists who use speech recognition.
Don’t allow use of the system to be
voluntary.
Have realistic expectations and plan
for a drop in productivity. Most studies
show at least a 10% reduction in radiolo-
gist productivity after implementation of
speech recognition. There are some ex-
ceptions, however. For example, at the
community hospital profiled earlier, my
colleagues and I all felt strongly that we
were more efficient when using the inte-
grated PACS-speech recognition product.
The University of Pittsburgh showed
at least a time-neutral effect after installa-
tion of speech recognition using a hy-
brid transcriptionist-radiologist editing
process and some modifications in work-
flow.6 Massachusetts General Hospital
(MGH) recently did a productivity study
of PACS and speech recognition in col-
laboration with New York University.
They were able to show that at MGH the
use of PACS had a positive impact on
radiologist productivity, while speech
recognition had no statistically signifi-
cant effect on productivity.7
Plan for training and ongoing support.
Even experienced users will have prob-
lems now and then. When new radiolo-
gists join the department or locum
tenens radiologists arrive, they will need
support on the system.
Set a deadline for the removal of con-
ventional transcription and transition to
speech recognition. Consider using a
hybrid model for report editing. One way
to use speech recognition is to have radiol-
ogists dictate, edit, correct, and sign their

26 ■ SUPPLEMENT TO APPLIED RADIOLOGY ©

www.appliedradiology.com December 2008

own reports. Another way is to have radi-
ologists dictate reports, and then use
“back-end” transcription for editing. In
this process a transcriptionist listens to an
audio file while viewing the text and mak-
ing corrections. Although this approach
relieves radiologists of clerical work, it
reduces cost savings and results in vari-
able turnaround times. Consider combin-
ing these 2 approaches, so that radiol-
ogists who are proficient with speech rec-
ognition can work independently and
those who are struggling or in a time bind
can send reports to back-end transcription.
Christiana Care Health System in
Wilmington, DE, provides an example
of a hybrid model for report editing. All
radiologists use speech recognition but
are given the choice of self-editing or
back-end transcription. Approximately
half of the radiologists choose to use
self-editing 80% to 90% of the time,
and about half of the radiologists send
their reports to back-end transcription.8
Take steps to maximize efficiency.
With speech recognition, efficiency is
determined by accuracy, navigation,
integration, and macro use. To maxi-
mize accuracy, it is best to use a headset
microphone. This will improve accu-
racy by standardizing the distance and
the position of the microphone in rela-
tion to the mouth. With a hand-held
microphone, approximately half of the
errors can be attributed to not holding
the microphone in the correct position.
Make corrections properly, either
using the correction mode or, in the case
of some speech recognition systems, the
vocabulary editor. This is a way of train-
ing the system to learn each user’s spe-
cific speech patterns.
Pay close attention to ambient noise.
It may be helpful to have the walls of
the reading room covered in acoustic
paneling and to have acoustic tile or car-
peting installed on the floor. If ambient
noise remains a problem, consider put-
ting in a fan or some device that gener-
ates “white noise.”
Speech recognition requires not just
dictation but navigation through the
text and various screens of the speech
December 2008
recognition system, as well as simultane-
ous navigation through the PACS. It is
important to consider how to make this
process seamless through use of a mouse,
a microphone with programmable but-
tons, or some other navigation aid.
Integration is another critical factor
in efficiency. It is fairly easy to use a
stand-alone speech recognition system.
It is much more difficult to achieve
interoperability between the speech
recognition system and the PACS or
RIS. The interface with the RIS needs to
be bidirectional, enabling the accession
number to pass from the RIS to the
speech recognition system, and in the
other direction, for text and any other
information to pass back to the RIS.
Even simple integration algorithms
can eliminate unnecessary tasks. With-
out them, it is necessary to first open a
case in the PACS, then open dictation in
speech recognition, and then add demo-
graphic information. Integration enables
distillation of the workflow into simply
viewing images, dictating, and signing
the report. The case is closed automati-
cally, the next case opens automatically,
and the radiologist views the images,
dictates, and signs the report.
Macros and templates are essentially
canned reports that the radiologist can
pull up anytime and modify. With
speech recognition, the use of macros
magnifies the time savings. Not only
does it save time in dictation, it saves
time in proofreading.
Figure 3 shows the modification of a
macro for a CT scan of the abdomen and
pelvis. The macro states: “Aorta is nor-
mal in size.” To modify that text, the user
verbally selects the sentence and substi-
tutes: “There is an aneurysm of the lower
abdominal aorta measuring 4.8 centime-
ter in diameter.” The user also changes
the impression from: “No significant
abnormality in CT scan of abdomen and
pelvis” to “Abdominal aortic aneurysm.
No other significant abnormality….”
All of the radiologist’s edits are done
verbally, without the eyes ever leaving
the images. Not only is this method
much faster than dictating an entire
www.appliedradiology.com SUPPLEMENT TO APPLIED RADIOLOGY
SPEECH RECOGNITION
report, the radiologist has only 2 phrases
to proofread.
Conclusion
Effective use of speech recognition
can yield major improvements in report
turnaround time. This technology is not
always well accepted by radiologists,
however, in part because it can reduce
productivity, at least initially.
To encourage radiologists to adopt
speech recognition, it is essential to offer
meaningful incentives. It is also helpful
to identify departmental champions who
can generate excitement about the new
technology, to set a firm date for discon-
tinuing conventional transcription, and
to maximize efficiency by improving
accuracy, streamlining navigation, inte-
grating speech recognition with the
PACS and RIS, and taking advantage of
macro functionality.
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