Artificial Intelligence for medical documentation

• AI scribes are just tools – you are responsible for their safe and effective use.
• Clinical notes generated by an AI scribe are only drafts – check for accuracy and make amendments during the consultation or soon after.
• Avant does not endorse or recommend any particular AI scribe.

The introduction of artificial intelligence (AI) into all aspects of our lives is happening quickly. In medicine, AI is being used for system efficiency, diagnostics, knowledge generation and preventive medicine. If you are unsure about what AI is or how it is being used, read our Introduction to artificial intelligence. Here we discuss the most common use of AI for GPs and physicians, AI for medical documentation.

An AI scribe ‘listens’ to the conversation between a patient and doctor then uses generative AI to compile a structured clinical note. Some AI scribes record the conversation, others simply process the audio but don’t record.

After the AI scribe has produced the draft clinical note, you need to check it for accuracy, correct any mistakes, include non-verbal cues and considerations, and then save it to the patient’s medical record.

As well as a clinical note, AI scribes can produce:

• patient information sheets
• referral letters
• care plans.

Check if your AI scribe is only a scribe tool that summarises a conversation or if it also includes clinical decision support tools to suggest clinical care. There are different considerations for clinical decision support tools than for scribe-only tools.

Some AI scribes are developed by health practitioners with clinical training, others are not. AI scribes may be incorporated within practice software and electronic medical records systems or may stand alone outside the practice system.

Potential benefits

• Improved patient communication through increased eye contact with the patient during the consultation. 
• Better patient understanding when you verbalise what you are doing during any examination. 
• More detailed documentation in the patient’s medical records. 
• Increased prevention or early intervention because of prompts to capture key information.
• Reduced time spent documenting via typing.
• Improved decision-making aided by accurate, detailed and up-to-date clinical notes.
• Reduced risk of transcription errors by creating multiple documents from the same source data.

Potential risks

• Compromised patient decision-making through an over-reliance on the tool.
• Patient harm caused by errors in clinical notes because they were not checked for accuracy.
• Privacy breaches if patient information is not managed in accordance with Australian privacy law.  
• Unknown clinical efficacy due to lack of regulatory oversight.
• Legal liability shifted from the AI scribe service provider to the user in the provider’s terms and conditions.

Privacy obligations

Privacy legislation requires you to inform patients about how you deal with their personal information, including how you collect and use patient information within your practice and who you disclose information to outside your practice.  

The company that provides your AI scribe is a third party that is outside your practice (even if the tool is incorporated within the practice software).

Some AI scribes aim to limit the collection of personal information by withholding or redacting identifying information, such as name and date of birth, from the AI-generated clinical note.  Redaction does not always mean that information becomes completely deidentified. If there is any chance the personal information can be reidentified, privacy obligations arise.

Because it is not clear whether any particular AI scribe keeps identifiable patient information, you should tell patients you are using the AI scribe during the consultation. 

Practice considerations

You should:

• update your privacy notice and policy to inform patients about the practice’s use of a third-party AI scribe to assist with generating clinical notes
• provide your patients with material from the service provider about how they manage patient information (you may also want to include general information about how the AI scribe works).

Consent

Because an AI scribe ‘listens’ to a consultation between you and your patient, it may be considered a listening device under state and territory listening devices legislation (although this has not been considered by the courts to our knowledge). Legislation differs in each state and territory as to whether specific consent is required for a party to a private conversation to make a recording. For more information see our article Watch out for pitfalls when recording your consult.

In the ACT, NSW, South Australia, Tasmania and Western Australia, consent is required from all parties to use a listening device to record a private conversation. This applies even if an audio recording is not being kept.

In Northern Territory, Queensland and Victoria, where specific consent is not legally required, it is prudent to obtain patient consent as a matter of transparency and good practice.  

Practice considerations

Obtain your patient’s consent to use the AI scribe at the beginning of each consultation. Consent may be verbal and should be documented in the clinical note for that consultation. Some AI scribes do this as part of the process.

Beyond any legal reasons, it is also ethical to discuss your use of an AI scribe with your patient. The use of AI in medicine is in a transition phase and there is a general lack of understanding about how AI works and a lack of trust in what it produces. Transparency about using AI will help build patient trust. Over time the use of AI will become an accepted part of clinical practice, and its use will be anticipated and accepted by most patients.  

Accuracy

As with all medical records, clinical notes produced with the assistance of an AI scribe must meet the requirements of the Medical Board’s Good medical practice: a code of conduct for doctors in Australia and the Medical Benefits Schedule (MBS), Health Insurance Act 1973 (Cth) and Health Insurance Regulations 2018 (Cth).

Be aware of the risk of assuming the notes are accurate because they read logically and legibly. An AI scribe has learnt how to generate legible notes but it has no understanding of the truth of what it produces.

The notes may appear accurate at first glance, but they may not be factually correct or complete. An AI scribe may not pick up nuances of the conversation between you and your patient nor can it include important non-verbal cues.

Inaccurate notes can contribute to treatment issues, including misdiagnosis. It will not be a defence to say an error was due to the use of an AI scribe. It is always your responsibility to review and check the notes for accuracy before including them in a patient’s medical record.

Some AI scribes can suggest MBS item numbers. You should not rely on an AI scribe to determine MBS requirements are met for each item billed. Responsibility for MBS billing remains with you, irrespective of whether an AI scribe is used. 

Practice considerations

Review AI scribe clinical notes during or as soon as possible after the consultation while it is fresh in your mind. This will ensure relevant observations, information and findings are included.

If personal information is withheld or redacted from the AI-generated clinical note you will need to:

• identify the patient (based on the time the consultation took place if it isn’t during the consultation)
• insert relevant information in the draft note before it is saved in the patient’s medical record.

Quality and safety

There is currently no regulatory oversight of AI scribes as they generally fall outside the Therapeutic Goods Administration (TGA) regulatory framework for medical devices.

Ensure there is a clinical or other benefit for using AI for the intended purpose. Seek to understand how it works, and evaluate its utility, safety and quality, so you can be aware of the potential risks and benefits associated with its use in your practice. 

Practice considerations

Ask yourself whether the intended task is something an AI tool should undertake. For example, producing a draft clinical note might be an appropriate task for AI but clinical decision making should always be undertaken by you, the doctor.

Regularly review the use of AI in your practice to ensure it is up to date, fit for purpose and meets its objectives. You should do this for all software used in your practice.

Avant factsheet: AI in healthcare: an introduction to artificial intelligence

BJGP Open Transforming healthcare documentation: harnessing the potential of AI to generate discharge summaries

For medico-legal advice, please contact us on nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.