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Excessive clinical documentation is a widespread problem that is causing clinician burnout and even having an impact on patient care – as an American Medical Informatics Association survey recently showed. It revealed the frustration of physicians and nurses about the burden of electronic health record charting and the time and effort needed to complete necessary documentation.There are technologies that can help. Many health systems are making use of natural language processing tools, generative artificial intelligence and ambient scribes to help their clinicians with EHR-documentation tasks.But these tools are not plug-and-play. To work effectively, they need to be customized around the specific needs of their clinical end users.
Dr. Dean Dalili, chief medical officer of DeepScribe, says customization with ambient scribes is an essential feature, particularly for medical specialties, because the ability to personalize note-taking reduces clinicians' time spent editing automated notes.To understand the impact of ambient AI documentation, consider the previous standards. Clinical documentation was paper-based and then moved to EHRs as part of [federal] policy. That transition has been good for quality and safety, particularly around medication safety, and physicians get better insight into the patient's context as they make a decision.
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