Using SGML for voice-enabled, structured medical reporting

Producing and storing medical documentation is time-consuming and costly Studies have shown that physicians spend upwards of 35% of their time on documentation, and the documents produced yearly number in the billions. Very little of this generated medical data is recorded in a format that is computer-readable. The result is a combination of high administrative costs and the inability of clinical decision-makers to use most of the data generated during the patient care process. Kurzweil Applied Intelligence has received a research grant from the National Institute of Standards and Technology (NIST) to build a prototype system which will use large-vocabulary voice-recognition technology to produce SGML-structured medical reports. SGMLaddresses the need for a structured reporting framework for medical applications because: SGML enables the preservation of context and structure in medical reporting, making the information gathered more useful and accessible. The current lack of a widely accepted standard format for medical reporting has limited the benefits of computerized patient records. The open systems approach of SGML facilitates communication among and porting between diverse platforms. The SGMLstandard supports a wide variety of information types in addition to text; images, video and audio clips can be incorporated into the medical report. SGML formats can be extended to meet the industry's changing requirements. Many of the issues surrounding the use of SGML in this project will be familiar to the general SGML community, particularly the advantages of tagging and structuring the data. In other respects, however, the project raises some new and interesting problems, such as the dynamic creation of SGML documents from a voice-controlled application. Another important issue is the lack of any standard DTD for clinical data. We have developed DTDs for patient demographic information, prescriptions, and primary care reports, and we are actively involved in the HL7 SGML Initiative, which is an effort to standardize healthcare DTDs.