Documentation capture

Nuance and the PRSB join forces to improve clinical documentation across the NHS

Nuance has joined the PRSB’s Standards Partnership Scheme to accelerate the adoption of information standards across the NHS. In this article, we look at why standards are essential for healthcare transformation and how conversational AI solutions like Dragon Medical One make it easier to implement them.

I’m excited to announce that Nuance is partnering with the Professional Records Standards Body (PRSB) to help NHS trusts implement standards for care records to improve patient care and safety and reduce clinician burnout. By joining the Standards Partnership Scheme, we’re bringing together the two pillars that support high-quality clinical documentation: speech recognition technology and information standards.

We’re at a pivotal moment in the evolution of the NHS. Trusts face the twin challenges of massive staff shortages and rising levels of burnout, just as they’re moving into a new world of integrated care systems that demand close collaboration and information-sharing between organisations.

With fewer staff being asked to do more, documentation quality inevitably suffers. And collaboration is tremendously difficult if patient information can’t be shared across systems and easily accessed by all stakeholders. The partnership between Nuance and the PRSB will help alleviate these challenges by supporting trusts to implement care record standards and reduce the documentation burden with AI technology.

AI supports information standards in clinical documentation

Advanced speech recognition technology enables clinicians to easily capture the complete patient story just by talking. Dragon Medical One, our conversational AI workflow assistant and documentation companion, empowers clinicians to automatically create comprehensive clinical notes directly in the electronic patient record (EPR).

Replacing keyboards with microphones dramatically reduces the time needed to create accurate, detailed clinical documentation. But Dragon Medical One offers so much more than simple dictation, with voice commands and AutoText functionality that enable clinicians to insert commonly used text and customised templates into records without having to dictate them.

Importantly, when we’re supporting trusts to build AutoText templates, we ensure they align with PRSB standards, so they can be easily shared across users, departments, and organisations.

One example of the value of standardised AutoText templates was the COVID-19 content pack Nuance made freely available for all Dragon Medical customers in the UK. These easy-to-use documentation templates helped providers capture crucial data points for COVID-19 patients in a consistent format to increase the quality and timeliness of their care.

As well as helping to implement information standards, AutoText functionality significantly reduces the clinical documentation burden. At Oxford University Hospitals NHS Foundation Trust , Dragon Medical One users (representing about 22% of active users) collectively saved 48 Full-Time Equivalent days on documentation in one year by taking advantage of AutoText.

Collaborating to enable high-quality clinical documentation

Our partnership with the PRSB will help us support more trusts to implement information standards using conversational AI technology, so they can improve patient care and safety, and alleviate burnout. Together, we’ll help clinicians capture the complete patient story and create high-quality documentation with less effort, and we’ll make it much easier for organisations throughout the NHS to share and access vital patient information. It’s a big step on the journey towards better, more accessible patient records that will help us deliver more precise, personalised, and timely patient care.

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Dr. Simon Wallace

About Dr. Simon Wallace

Dr. Simon Wallace is the Chief Clinical Information Officer (CCIO) of Nuance’s Healthcare division in the UK and Ireland. Simon has worked as a GP, hospital and public health doctor in Brighton and London. His interest in health informatics began in the 90s when he spent a year at the King's Fund investigating the impact of the internet on shared decision making between patients and their healthcare professional. For the past 15 years, he has worked for a range of organisations including Bupa, Dr Foster, Cerner Corporation and GSK across a range of technologies which include electronic patient records, telemedicine, mobile health and lifestyle devices. Simon has a keen interest in the voluntary sector, recently completing a 7 year term as a Trustee for Fitzrovia Youth in Action, a children and young people’s charity based in London.