For healthcare professionals who are not already using an artificial intelligence (AI) scribe, it’s possible they are thinking about it, or planning to use one in the future, as a recent member survey conducted by Avant Mutual found.
Inevitably, some aspects of a physician’s practice will need to change to start doing this.
AI scribes “listen” to the consultation and process the audio into a structured clinical note. Because physicians do not need to write or type during the consultation, they can direct more attention to the patient. As well as taking away some of the documentation burden, this offers benefits for patients as the clinician is able focus on them more and listen to their history and discuss their condition, treatment, and management.
In the case of a physical examination, this will not automatically be picked up by the AI scribe. So how does the physician convey the relevant information to ensure it's captured in the clinical note?
Capturing the physical examination
The patient should already be aware that an AI scribe is being used and should have consented to its use at the start of the consultation.
Clinicians should first consider their consultation style to best capture the physical examination. Practitioners who have started using AI scribes have reported the most effective way of capturing the physical examination is to say what they are doing, both before and during the examination.
Some doctors will adjust their consultation style by verbalizing and “dictating” their examination findings out loud so it can be captured by the AI scribe and as a memory aid. However, they need to be mindful of the use of medical jargon in front of the patient, as this may trigger further questions from them.
Alternatively, doctors may continue with their usual approach for conducting the physical examination using plain language. That is, explain examination findings while examining the patient or explain to the patient the examination findings after completing the physical examination.
The AI scribe may be able to interpret examination findings and record under “objective findings” or “examination” as a basis for the clinical note.
It is imperative to review and edit the clinical note afterwards to ensure the record accurately represents the full examination, including any positive and negative findings as well as non-verbal cues noted.
Improved patient engagement
The process of verbalizing an examination for the AI scribe can improve communication and patient understanding. It also provides an opportunity for patients to engage with you during the examination and prompts them to ask questions.
If you verbalize your examination out loud as you go using medical jargon, make sure you manage your patient expectations and avoid unduly worrying them by adequately explaining what this terminology means. It may also help the patient if you explain exactly why you have verbalized certain relevant positives and negatives as part of your diagnostic thought process.
One of the unexpected benefits of using an AI-scribe is that describing to the patient what you are doing, and why, can reduce the risk of unintended confusion or miscommunication. This is a common source of patient complaints, particularly when an intimate examination is needed.
Documentation responsibilities
Physicians are responsible for the accuracy of the final clinical note, so they should always review the note and make any corrections or additions before saving it to the patient’s medical record.
As with all medical records, clinical notes produced with the assistance of an AI scribe must meet the requirements of—in this case--the Australia Medical Board’s code of conduct, the Medical Benefits Schedule, Health Insurance Act and Health Insurance Regulations.
Information or aspects that may be omitted from the AI-generated note include non-verbal cues from the patient, or the results of a mental state examination. Information may also be missed, incorrectly categorized or misheard, such as names of referring doctors, medications, or unusual symptoms.
Or there may be areas of sensitivity for the patient that a physician chooses not to verbalize. An example might be a patient with an eating disorder and not highlighting their weight or BMI calculation. Or, the doctor may wish to document other aspects not picked up by the AI-scribe, including trends in vital signs, such as blood pressure.
It is important to have a process to ensure this information is added to the final clinical note.
As well as checking the accuracy of the AI-generated note for a consultation, new information gathered, such as a chronic health condition, allergies, social and family history should be used to update or amend information in other sections of the patient’s record.
Key take-aways:
- As the technology and integration of AI scribes improves, they offer the promise of potentially easing the administrative burden for doctors, and improving the quality of communication and documentation.
- Using an AI scribe can support clear communication with patients and may be a good way of explaining what you are doing in an examination, and why, to avoid misunderstandings.
- Remember though, an AI scribe is just a tool, and the clinician is ultimately responsible for its safe and effective use. So always check the generated clinical note to ensure it is accurate and complete.
This article is informed by an Avant Mutual survey: Avant calls for proactive regulation as AI scribe use by doctors gathers pace.