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Visiting the doctor can be a harrowing experience for many patients, especially when it’s time to take prescriptions to the pharmacist, who must decipher what they say. Poor penmanship and lack of time are two reasons why when it comes to taking notes, many doctors prefer to use voice recorders. But how to get those voice notes onto paper, where they can be used?

Dr. J.B. Harlan, an ophthalmic surgeon at Sinai Hospital of The Krieger Eye Institute, in Baltimore, was the first doctor moved over to Dynamic Technology Systems Inc.’s new medical transcription system that automates much of the process of converting voice notes into text.

As an early adopter, Harlan said he already sees the benefits. “This gives me the freedom to get my dictated information in print with minimal effort,” he said. “I can edit it immediately the way I want it, and I can have access to it anywhere. My work involves a lot of complicated stuff, and I need good documentation … certainly more than my poor handwriting.”

The system was developed by Ajilon Consulting for DTS in a project that moved DTS from a Unix-based platform to Microsoft Corp.’s .Net platform. Since the data being transported is not only mission-critical but also life-critical, the system went through some rugged testing via Microsoft’s VSTS (Visual Studio Team System).

“We built a solution for them on lots of cool Microsoft stuff,” said Brad McCabe, lead developer on the project at Ajilon, based in Towson, Md. “My favorite thing is that it uses the new Microsoft Speech Server to provide a second interface to the application. A doctor can call up, log in and dictate his note right over the phone. The dictation is then routed, just as if a file had been sent from a handheld recorder through the system to the transcriptionist and back to the doctor.”

DTS, of Parkville, Md., handles medical transcription for a host of doctors and hospitals in the Baltimore, central Maryland and Washington areas, including Johns Hopkins Hospital, the University of Maryland’s Department of Neurosurgery and Division of Otolaryngology, and Sinai Hospital, said Tim Montague, president of DTS.

The system is scheduled to go live next month to all the company’s clients, Montague said.

The process starts with a doctor dictating notes or letters about patients into a handheld Olympus America Inc. DS-330 Digital Voice Recorder. The recorder is then placed into a USB (Universal Serial Bus) cradle connected to a PC to download the audio files.

This is where the new system developed by Ajilon steps in. A .Net application on the PC monitors the Olympus folders. When new files arrive, the system sends them via a secured FTP connection to DTS, where they are loaded into a system that routes them to transcriptionists at DTS locally or in India.

The arrival of the files is signaled by a pop-up message, and a transcriptionist converts them to Word documents. The finished documents are routed back to DTS’ quality assurance department or to the doctor, who also is notified via a pop-up.

In the past, transcriptions could take five days to get back to doctors. “With the new system, we guarantee 95 percent of your stuff will be back to you within 24 hours,” Montague said.

The system lets doctors send one or many notes to other doctors in an e-mail, or they can enter a phone number and the Word documents are converted and faxed automatically to that number, McCabe said. “This allows a doctor standing in the ER to fax or e-mail notes to another doctor in an emergency.” The application has Windows client and Web interfaces.

Montague said that the new .Net-based system mirrors the existing one but that the new features and Windows support make a big difference, particularly in making changes to the application more quickly.

The custom solution Ajilon delivered is designed to be adaptable, Montague said. “I said I’d like to do my own system, one developed the way I wanted it to be used. We covered all the things the doctors wanted,” he said.

The Ajilon team took the system through rigorous testing leading up to production.

“Initially, the system was unit-tested by the development team,” McCabe said. “This was greatly aided by the code coverage and testing tools in Visual Studio Team System. While [the product was] only in beta, we were able to make extensive use of this product [VSTS] to help ensure the system’s quality. With three different interfaces powered by a core set of Web services, the testing was critical. Any change had to be verified in multiple locations. Using some of the automatic testing tools in VSTS cut this time dramatically.”

Prashant Sridharan, senior product manager for VSTS, said, “With Visual Studio Team System, Microsoft incorporated quite a few enhancements for testing capabilities. This is a major tenant for Team System, as testers are a big target audience.”

Next page: Cost and Scalability.

In addition, besides lessening the systems’ testing time, VSTS enhanced the quality of the testing. “By using prewritten test scripts, we were able to ensure that each time the application received the same level of testing. When a person is doing repeated regression testing, the odds of missing a step or function are much higher than when you are running scripts.”

After initial testing, Ajilon took the system through a complete system-level test to ensure that all the pieces worked together; then the system moved to a UAT (user acceptance testing) period.

“Using an automatic set of testing tools was a big help during UAT,” McCabe said. “While we had worked very tightly with the end-user community and did many demos, discussions and prototypes, there was still a normal level of change requests during UAT.”

“No matter how hard you work together, there are always a few things that pop up when users work with the entire product and discover and desire some process modifications,” McCabe said. “Having a set of scripts allowed us to make those changes late in the cycle but still have the ability to rapidly and completely test the functionality of the product.”

John Keefauver, Ajilon’s service director of applications development and support, said, “Ajilon has a series of best practices and lessons learned from over 30 years of building software. We understand the importance of software quality assurance and how it affects the product that we deliver to our clients. Ajilon tailors our SQA approach on a project-by-project basis because obviously a small project’s SQA needs are much different than a large-enterprise application. In the case of DTS, the SQA efforts were closely coupled with the development cycle to enable us to move very quickly and deliver a quality application.”

Montague said DTS went through about four weeks of user testing on the system. “We let the actual users use it and make suggestions on what would make it work easier for them,” he said.

Meanwhile, McCabe said Ajilon selected the Microsoft products based on two requirements: cost and scalability.

“First, we were looking to control that overall cost for the project, but the second concern was scalability,” McCabe said. “We project significant growth in the business as a result of the release of this system. This meant that while we needed an economic solution today, it had to be able to scale up to massive sizes in short order.”

“We looked at various open-source solutions on the market but settled on a Microsoft-based solution. We were able to build our solution on products such as SQL Server Express and Windows SharePoint Services with limited licensing fees,” McCabe said. “As the business grows, we have a very clear upgrade path to SQL Server Standard or Enterprise editions and also SharePoint Portal Server.”

Moreover, “By managing our cost on these parts of the solution, we were able to spend more on advanced features like the Interactive Voice Response system that uses Microsoft Speech Server 2004,” McCabe said.

In addition, all the core business processes are in a set of Web services, McCabe said. “These same services are used on the Web interface, the Windows Forms interface and the Interactive Voice Response interface. Some call it SOA [service-oriented architecture],” he said.

Future versions of the system will include support for PDAs and mobile devices, McCabe said. “We have designed the system based on an SOA model with a core set of Web services supporting the current Web, smart-client and IVR interfaces,” he said. “.Net provides users great support to develop a mobile interface [that] will easily plug into our architecture in the next version.”

Benefits of the new system include increased turnaround time on transcriptions, with the pop-up messages alerting users when work is available. The system’s new search and help capabilities are also key system benefits, Montague said.

In addition, Harlan said he likes the new system’s search capability. “I can pull off any notes I’ve dictated, ever,” he said.

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