Main image courtesy of Popular Science.

Clinicians of all varieties perform a lot of different tasks on a daily basis. Most of these duties are dedicated to the wellbeing and care of their patients, but there are other tasks that are more administrative in nature and can end up being quite time consuming. One of those crucial but mundane jobs is ensuring proper documentation of encounters and ongoing treatment plans. Typically you’ll find providers entering this information during the patient’s visit, afterwards, or at the end of the day. This is not only more work for them to worry about, but it can also be quite distracting to accomplish during an encounter.

One of the best solutions to this issue is using ambient medical scribes powered by artificial intelligence. But what exactly do these AI programs do, and would they be a good fit for your practice?

In today’s piece, we’ll be covering:

• What ambient medical scribes are
• How AI scribes help with medical documentation
• The benefits of using an ambient AI scribe

What is an ambient medical scribe? 

Would an AI scribe help your practice?

In the past, clinicians and other healthcare workers did not have a choice regarding how to input their daily notes and make important updates to patients’ files. In the past this was all handwritten either during the appointment or at a later date. But with the advent of electronic health records (EHRs), this could be done from a computer or tablet. However, it still required the provider to put in important medical and patient data into the file as the encounter progressed, potentially distracting them from listening fully to what the patient had to say.

If this medical documentation wasn’t done during the visit, then it would need to be put in after the fact, usually lengthening a provider's day. This health data is essential to keeping accurate and up to date files that list all the necessary information, treatment plans, medication, and any diagnosis or procedures that have taken place. 

AI has already made its way into many fields to help with more mundane tasks, and it was only a matter of time before it became more widespread in healthcare. One of the major ways that artificial intelligence can help in healthcare is as an ambient medical scribe. This is an application that can be downloaded to a smartphone or tablet and uses natural language processing and learning algorithms to listen to a doctor/patient conversation and transcribe it. There is no extensive training required, and all doctors have to do is get consent from the patient and turn the app on. 

It will start listening, capture important information, put it in any typical format (such as a SOAP note), and prepare it for review. This crucial documentation could include an updated medical history, any findings from an exam, updates to treatment or prescriptions, and any necessary follow up appointments. Using an AI scribe also ensures that the doctor is not worried about missing information because they’re trying to type as the patient speaks. 

All ambient scribe notes need to be reviewed by the clinician to ensure that they’re correct and summarized what took place at the encounter. The provider can also choose to add any additional notes to the file before it is sent to the patient’s EHR. After the note is in the EHR, the AI scribe will not keep any record or other copy of the information, which is essential since this is important patient data. 

What is ambient medical documentation? 

Ambient medical documentation is how the AI scribe organizes the health data into a formatting that the clinician chooses. It takes the information from the transcribed conversation and updates all the necessary fields that are a part of a medical note. 

What are the 5 C's in medical record documentation? 

In order to turn the language it transcribes into useful medical notes, it’s essential that the ambient scribe follows the 5 C’s of medical record documentation. The information in the patient’s notes should be:

• Clear. One of the major perks of using an ambient medical scribe to transcribe notes is that it can easily streamline how the note is written, and include the right terminology to ensure information is recorded correctly. A lot of issues with medical notes that are documented by humans stems from the lack of consistency and not including all potentially relevant information. Human error is largely removed from the situation so you’re left with a clear description of the patient’s issue or concern.

• Concise. Medical documentation should also be concise, easy to read, and as brief as possible. Keeping notes that include all the important information but in a way that’s simple to digest makes it easier for clinicians to get answers and find what they’re looking for.

• Complete. Filling in the information as the encounter progresses is the best way to ensure everything is documented and accounted for. Humans who are doing this need to split their time between listening and examining the patient, then recording the information. However, with an AI medical scribe listening instead, there’s no reason to turn your attention away from the patient. Using an ambient scribe can assist with the creation of more complete notes.

• Confidential. Ambient scribes do not record or retain any of the patient information that they transcribe and send to EHRs, and it is encrypted. Protecting patient data like this is essential to ensure this vital information is not vulnerable to a hack.

• In chronological order. Each time a new encounter occurs, the note will be added to the EHR in chronological order. This is how a clinician can see the progress of the patient, and can determine what is working, and what should be tweaked.

Medical notes that are completed by ambient scribes also follow the 7 criteria for high quality documentation that include:

• Being clear
• Consistent
• Precise in terminology
• Reliable
• Uploaded timely 
• Legible

You can see how an AI scribe can help with all of those items, and create better notes that include all the relevant information in an easy to read way. 

How much does an AI medical scribe cost? 

If getting an ambient medical scribe sounds good to you, you’re not alone. More and more clinicians of all fields are finding it helps them save time and improves the accuracy and completeness of medical documentation. There are a lot of companies you can try out (many offer a free trial) to see what works best for your situation, and most operate on a subscription basis. Additionally, a lot of ambient applications have tiered plans that you can choose from to customize a better fit with your particular practice. 

You can expect to encounter ambient scribes that can cost anywhere from $99-$150 each month—which would not only cost you a lot less than using an actual medical scribe over the course of a year, but it offers time savings as well. A lot of clinicians find that their AI medical scribe is well worth the investment, and the benefits outweigh the costs. There are a few things to keep in mind during your search for an ambient scribe:

• Make sure it is HIPAA (and ideally SOC 2) compliant
• Ensure it is not recording or storing data
• Does not need access to patient records to learn
• Can easily be synced with your EHR system

Pro tip: Playback Health’s AI scribe checks all the above requirements, and then some! 

Will AI replace medical scribes?

Medical scribes are people who accompany a doctor throughout their visits with patients and are responsible for transcribing the encounter in the EHR in real time. Most scribes work closely with the physician to ensure that all the information is accurately put into the record, allowing the provider to focus solely on patient care. The clinician does not need to worry about updating records because it is done at the time thanks to the medical scribes.

Medical scribes are still an in-demand job, especially in very busy places like emergency rooms. They can ensure the information is written correctly and can ask for any clarification if required. However, because ambient scribe applications are so easy to use, they may start to make their way into more healthcare facilities as the years go by. AI can never fully operate by itself, as it still requires a human to review and double check that the information is correct. But chances are we'll see more AI scribes in healthcare settings.

Benefits of using an AI medical scribe

Ambient medical scribes come with a lot of advantages

There are some considerable advantages to using an ambient medical scribe in your daily practice, no matter what your speciality is!

• Automates note entry. This is one of the top benefits of an ambient medical scribe in that it can automate note creation and entry. Doctors are no longer responsible for sitting down and creating new notes for each and every patient, and instead can rely on the AI scribe to transcribe conversations and turn them into summaries and updates to the patient file.

• Frees up clinician time. When clinicians no longer have to sit down at the end of the day and fill in electronic notes, or take notes during an encounter, they’ll find that they have a little more free time during the day. Ambient medical scribes can take care of the mundane but necessary administrative tasks like note taking, automating registration/check out, and scheduling any additional appointments for the patient. Having a little extra time to themselves or to spend with their patients can make for happier providers. 

• Improves accuracy. A lot of mistakes in notes or EHRs are due to human error when someone omits information or puts the incorrect information in it. AI scribes have a higher degree of accuracy compared to humans, and although it will still need to be checked for correctness, they are generally more complete and accurate. 

• Streamlines workflow. Once the note is ready and reviewed, it can immediately be added to the patient’s EHR. If something needs to be shared from the patient’s data, it can easily and securely be sent to another provider. 

• Improves patient/doctor relationships. Not having to worry about entering information at the time of an encounter is a great way to limit distractions and allow the clinician to focus on the patient. When the AI scribe is transcribing everything, the provider no longer needs to worry about missing information or mishearing the patient because they were trying to type in information. Instead they can focus on the concerns of the patient, which leads to higher rates of patient satisfaction.

• Updates and shares across devices. When the note is done and the doctor has reviewed it, the patient’s record is updated across all devices. This means everyone on the healthcare team is working with the most up to date information for all patients. 

• Reduces costs. Even with a monthly subscription, the cost of an ambient medical scribe is much lower than hiring a human medical scribe. AI scribes also have a higher degree of accuracy, do not need extensive training, and there is little to no learning curve.

Do you think an ambient medical scribe is right for you?

Now that you’re aware of some of the advantages of using an AI scribe, is it right for your practice? There are a variety of options out there, but if you’re looking for a scribe that can save time creating concise notes, can listen to conversations, and that updates all devices instantly, consider checking out what Playback Health has to offer.