Patient care documentation benefits from dictation tools, AI

Physicians spend a lot of time entering clinical data and notes into EHRs. AI, natural language processing and dictation tools can alleviate the burden of care documentation.

With the increasing use of EHRs, physicians are spending more time in front of the computer completing charts than they did in the past when they used paper charts for patient care documentation. Despite the use of picklists, templates and point-click options, improvements in efficiency were modest. However, the use of dictation tools and medical scribes has provided some of the most promising results in reducing physician burnout thus far. Combining advances in AI with dictation is showing even more drastic improvements that will change the way physicians interact with patient charts.

EHRs spur innovation, alternatives to speed data entry

Since the introduction of electronic charts, some physicians have found that entering clinical data electronically often takes longer than taking notes on paper. However, considering the gains related to storage, data sharing and patient reporting, the thought of spending a little more time looking at a computer screen does not seem all that terrible.

Nonetheless, the result of the burden of long periods spent by physicians on multiple screens within the EHR has motivated many vendors to innovate and seek ways to improve end-user experience. Some of the changes have been seen within the EHR systems themselves in features such as picklists, note templates, order sets and integration with voice dictation systems.

Despite best efforts to improve the EHR package by creating shortcuts, some physicians still have a negative opinion of systems where they felt the software created more work for them and distracted them from having adequate patient-physician interactions. In some instances, hospitals resorted to providing some assistance to providers by hiring scribes to help with clinical documentation and reduce the burden on physicians when it comes to data capture into the EHR. A recent survey published in the Annals of Family Medicine highlighted that over 53.2% of the surveyed physicians were satisfied with using a scribe and that more charts were closed within 48 hours when scribes were present.

Dictation tools improve documentation, reduce burnout

Another alternative to using scribes for patient care documentation has been the implementation of dictation tools. In recent years, there has been more emphasis on the efficiencies that some of the latest dictation tools offer -- and physicians are beginning to pay attention to them. Thanks to the advancements in natural language processing and investments by some of the top players in AI, patient care documentation through dictation is taking on a whole new meaning. The tools that are currently available offer a much higher accuracy when it comes to detecting medical terms, understanding the context, extracting data elements from the dictation and populating it directly into the EHR.

Last year, Google described a use case in which one of the research projects conducted with Stanford University allowed them to apply speech recognition for medical conversations. The idea was to use their voice technology and AI to capture the physician's intended notes, and accurately capture and predict medical terminology from a conversation between the physician and patient, which would amount to a virtual scribe or "scribebot."

Benefits of AI and voice recognition

The use of AI with voice recognition systems in healthcare will help on several fronts that go beyond just improving patient care documentation. Some of the benefits include:

  • reducing burnout rates among physicians due to excess work around clinical documentation;
  • real-time analysis of dictated content to help reduce errors and improve accuracy;
  • extraction of key data elements from voice and populating specific areas within the EHR;
  • reducing the dependency on scribes within hospitals;
  • increasing chart completion compliance;
  • capturing meaningful conversation-based data from care collaboration sessions;
  • integrating with any EHR system for data capture; and
  • support for data capture from anywhere, including mobile devices.

Thanks to AI, the shift seen in dictation systems where they are becoming more than just a voice-to-text tool will have a significant impact in healthcare. Improvements in patient care documentation, along with happier clinical staff, are just a couple of the main benefits of such tools that are changing the way users interact with their EHR. As we slowly move into the "scribebot" model, there are some concerns around potential reliability and accuracy. However, tools that are currently available have shown promising results by reducing wasted time interacting with software interfaces and using a more natural approach to the use of voice and AI.

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