Real-Time Report Dictation in Endoscopic Procedures: Quality and Efficiency

Aims The evolution of endoscopy reports has accelerated with the introduction of computer systems, which have become indispensable tools in clinical practice. Various endoscopy society guidelines emphasize the importance of standardized reports to improve the overall quality of endoscopic procedures. However, limited time due to clinical workload often hinders the creation of high-quality reports. Real-time report dictation systems during endoscopic procedures could improve the quality and efficiency of endoscopic documentation.

Methods This six-month prospective randomized study included 313 colonoscopies, randomized into standard reporting (SR) and real-time dictation reporting (RTDR). Reports were evaluated individually and with specialized text analysis software to assess errors and report characteristics. The primary objective was to optimize the time from procedure completion to report signing. Secondary objectives included reducing orthographic and typographic errors, increasing report clarity, and improving adherence to quality indicators such as withdrawal times [1] [2] [3] [4] [5] [6].

Results A total of 151 SRs and 162 RTDRs were analyzed. The cohort included 169 women (54.0%) and 144 men (46.0%) with a median age of 59 years [IQR: 49–69]. The most frequent indications for colonoscopies were altered bowel habits (15.2%), familial colorectal cancer (11.7%), rectal bleeding (11.7%), polyp surveillance (10.0%), abdominal pain (9.6%), and anemia (8.3%). RTDR significantly reduced the report drafting time by 1 minute (median [IQR]: 5.0 [4.0–8.0] vs. 4.0 [3.0–6.0], p<0.001). RTDR also demonstrated lower error rates for orthographic (1.7 vs. 3.5, p<0.001) and typographic errors (0.2 vs. 0.7, p=0.001). Reports with RTDR included withdrawal times in a significantly higher proportion of cases (37.0% vs. 13.9%, p<0.001). In patients with prior colonoscopies (119 SRs; 107 RTDRs), the degree of concordance between prior and current findings was assessed using Cohen’s Kappa coefficient and correct classification rates. The results (SR/RTDR) were as follows: polyps (59.5%/59.0%), diverticula (79.7%/75.6%), scars (97.3%/93.6%), tattoos (97.3%/98.7%), and anastomoses (94.6%/94.9%).

Conclusions Real-time dictation significantly improves report efficiency, reduces errors, and enhances diagnostic concordance and adherence to quality indicators in endoscopic procedures. These findings highlight the potential of RTDR systems to improve endoscopic reporting, supporting their integration into routine clinical practice.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Beaulieu D, Barkun AN, Dubé C, Tinmouth J, Hallé P, Martel M.. Endoscopy Reporting Standards. Can J Gastroenterol 2013; 27 (05): 286-92
• 2 Armstrong D, Barkun A, Bridges R, Carter R, de Gara C, Dubé C. et al. Canadian Association of Gastroenterology Consensus Guidelines on Safety and Quality Indicators in Endoscopy. Can J Gastroenterol 2012; 26 (01): 17-31
• 3 Borgaonkar MR.. Making a Quality Endoscopy Report. Can J Gastroenterol 2013; 27 (05): 258-258
• 4 Groenen M, Ajodhia S, Wynstra J, Lesterhuis W, van de Weijgert E, Kuipers E. et al. A cost-benefit analysis of endoscopy reporting methods: handwritten, dictated and computerized. Endoscopy 8 de julio de 2009; 41 (07): 603-9
• 5 Bisschops R, Areia M, Coron E, Dobru D, Kaskas B, Kuvaev R. et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 22 de agosto de 2016; 48 (09): 843-64
• 6 Rizk MK, Sawhney MS, Cohen J, Pike IM, Adler DG, Dominitz JA. et al. Quality indicators common to all GI endoscopic procedures. Gastrointest Endosc enero de 2015; 81 (01): 3-16