Ambient clinical documentation shows promise for physicians

Robert A. Dowling, MD

Physicians in all specialties continue to struggle with burnout, and the burden of clinical documentation—exacerbated by time-consuming workflows in the electronic health record (EHR)—is known to be a major contributor to this epidemic.¹ In the past few years, physicians have employed different strategies to reduce the amount of time spent on documentation. Text-to-speech tools using natural language processing were first introduced in the late 1990s and eagerly adopted by some physicians, primarily to replace expensive medical transcription. The accuracy of these products has continued to improve, but not all physicians have embraced the technology. Another approach has been the use of scribes—documentation assistants at the elbow of the clinician, transcribing the encounter in real time and freeing the physician to focus on the patient. Some scribes use natural language processing tools to document. Another approach is virtual scribes—individuals at a remote location listening in on the physician-patient conversation and transcribing without the intrusion of another human in the room. All these approaches have pros and cons, and certainly one solution does not fit all tastes—perhaps until now. In this article, I will discuss the latest innovation in this space: ambient clinical documentation.

Many readers are familiar with the digital voice assistant Alexa, or for iPhone users, Siri. Once engaged, these artificial intelligence (AI)–powered tools can recognize commands and questions and respond with appropriate information or actions. Ambient clinical documentation works in much the same way. Once triggered, the software listens to a physician-patient conversation and generates a clinical note by summarizing the content of the conversation in a familiar format—for example, history of present illness (HPI), assessment, and plan. Integration with the EHR allows for seamless transfer of the notes into the appropriate section of the EHR. Several specialized vendors have emerged as contenders in the space, including Nuance (Dragon Ambient eXperience, or DAX), Abridge, Ambience (AutoScribe), ScribeAmerica (Speke), 3M (M*Modal Fluency Align), DeepScribe, Nabla (Copilot), and Suki (Assistant Gen 2). All of these vendors tout integration with 1 or more major EHRs, and other EHR vendors appear to be releasing their own branded tools (ie, NextGen’s Ambient Assist).

To get a better idea of how urologists are adopting this technology, I recently spoke with Vikram Narayan, MD, assistant professor of urology in the Department of Urology at Emory University School of Medicine and director of urological oncology at Grady Memorial Hospital in Atlanta, Georgia. After a successful pilot in Narayan’s clinical practice, Abridge was implemented across all 35 urology providers in the larger organization in September 2023. Here’s how Narayan described the workflow: He pulls up his daily schedule in the Abridge app on his phone, taps the patient’s name as he enters the room, and obtains verbal consent from the patient to record the encounter. The entire conversation is recorded as he visits with the patient, and once the visit is complete, a summary derived from generative AI is created that includes an HPI, assessment, and plan. (Abridge can also function as a dictation tool.) The accuracy “is amazing,” according to Narayan. The verbatim transcription and sourced sound recording are also stored and available if needed. The summary note can be pushed to the EHR (Epic) from the phone app or later from a desktop version. Abridge was integrated with Epic in a way that permits the continued use of macros, smart phrases, and copy-forward tools in the EHR for those physicians who are accustomed to those efficiencies in documentation. Early metrics of success in this urology implementation include a 25% increase in encounters closed same day and anecdotal reports of 1 to 2 hours per day of time returned to some physicians. Narayan said that the tool allows him to pay more attention to nuances in the patient conversation that could bear on diagnosis or treatment, and he feels less mentally fatigued at the end of a busy clinic. Powerful testimonials from some of Narayan’s colleagues include the following: “OMG! Abridge is amazing. It works quite well. I tend to be a bit less wordy, but when it puts the HPI together it is just so easy to edit it down a bit…this made such a difference today.” “Abridge works great. I had all of my notes done in under an hour and encounters closed by 6 pm, which never happens.” “This is definitely the future.”

Narayan acknowledges there are some limitations. Currently, these tools are not configured to document the physical exam, but, as he explains, that is usually not a time-consuming task and often not even a part of an established patient visit. Also, he says the generative AI tends to be a little verbose and physicians end up trimming flowery or unnecessary text. “There is still some cleanup needed,” he says. He hopes to soon have more objective metrics on time saved, closed encounters, and physician and patient satisfaction. Meanwhile, Emory Healthcare has signed an enterprise-wide agreement to make Abridge available to more than 3450 clinicians across its system.²

The bottom line and why it matters

Clinical documentation is a recognized contribution to physician burnout, which in turn can lead to negative outcomes for patients and physicians. Ambient clinical documentation is a new application of AI that holds some promise to relieve that burden, reduce burnout, and return time and satisfaction to physicians. Urologists should consult with their EHR vendors or partners to learn more about what ambient documentation tools can do in your own practice.

References

1. Gesner E, Gazarian P, Dykes P. The burden and burnout in documenting patient care: an integrative literature review. Stud Health Technol Inform. 2019;264:1194-1198. doi:10.3233/SHTI190415

2. Abridge becomes Epic’s First Pal, bringing generative AI to more providers and patients, including those at Emory Healthcare. News release. Emory University. August 16, 2023. Accessed October 13, 2023. https://news.emory.edu/stories/2023/08/hs_ehc_abridge_epic_ai_ambient_listening_tool_16-08-2023/story.html