Should you use AI documentation tools?

Up to one-third of a doctor’s day can be taken up with paperwork. What if a tool could give you back some of those hours? Artificial intelligence (AI) medical documentation tools, sometimes known as scribe tools, are being touted as the answer. But before you jump on board, attracted by the various benefits this software can bring to your clinical practice, you need to be aware of a few things.

How AI documentation tools work

AI medical documentation tools listen to a doctor-patient consultation, extract clinically relevant information, then quickly collate and structure the information into a coherent clinical note. These AI-generated notes need to be reviewed and amended by you, the doctor. Amendments may include incorporating examination findings, test results, non-verbal information, unsaid thoughts and identifying patient information.

The AI tool can also generate other documents such as a summary letter or treatment plan, referral letters, or a discharge summary. Using this functionality reduces the risk of transcription errors when dictating the information to go in these documents individually. Over time, your AI tool can also learn your personal style, so the notes will look and sound like they’ve been written or dictated by you.

Time savings and improved consultations

The potential time savings from using an AI medical documentation tool could be significant. But time savings aren’t the only benefit. Communication in your consultations may improve because you are able to give your patient more attention, as you’re not trying to write or type at the same time.

After using one of these tools for a while, you may also find yourself verbalising observations and thought processes so they’re noted, which would increase transparency during the consultation. The AI-generated notes may also be more comprehensive than your usual notes.

AI-powered tools can incorporate checklists or prompts to reduce the risk of omitting key information. This may improve diagnostic accuracy and continuity of care and assist with recommendations for preventative measures or early intervention.

Be aware of the possible downsides

All new technology comes with some risks and AI documentation tools are no different. Before using an AI documentation tool, do your own due diligence to determine whether the tool will meet your clinical needs without compromising the quality of your patient care.

Privacy, confidentiality and consent

Before using an AI tool, check that patient privacy and confidentiality will be protected. Where will the information be processed, where and how will it be stored (in Australia or overseas), and could the information be used for any other purposes?

If the AI tool records the consultation, make sure you have patient permission (and note that permission) before recording starts, even if the tool deletes the recording after processing it.

If you are using the tool to generate other documentation such as reports or referrals, check these don’t include extraneous clinical or other information.

Is your AI ‘medical grade’?

Not all AI is the same and the technology is still evolving. Make sure you use AI medical documentation tools that are trained to identify clinically significant information. Check with your colleagues or college for reputable tools. AI medical documentation tools currently fall outside the TGA’s medical device regulatory processes.

Patient considerations

Verbalising your observations and considerations for the AI tool may sometimes be clinically inappropriate. For example, you may not want to verbalise the BMI of a patient being treated for anorexia nervosa or your concerns about the cause of a patient’s injuries. Remember, you will need to add this information into the AI-generated notes later on, along with any clinically necessary non-verbal communications or cues.

Accuracy of records

AI’s tendency to fill in gaps or extrapolate findings, could produce a misleading record. You are responsible for making sure an AI-generated medical note accurately reflects the consultation. You need to check all notes and reports and amend as necessary. You also need to be satisfied there is sufficient detail to justify the Medicare item numbers you bill for the consultation.

More information

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

The article was originally published in Connect magazine 22.