Ambient Clinical Documentation: How AI Is Transforming the Future of Medical Scribing

Ambient clinical documentation is an artificial intelligence-powered tool that clearly and accurately notates conversations between medical professionals and their patients so that doctors can focus on providing targeted, personalized care. Ambient clinical documentation relies upon technology built with healthcare-specific data to create the relevant large language model for the industry. Moreover, as clinicians provide feedback, the AI system updates itself for even more accurate notetaking.

Use of highly reliable AI notetaking is more crucial today than ever before, given rising clinician burnout. According to Mayo Clinic’s Changes in Burnout and Satisfaction With Work–Life Integration in Physicians and the General US Working Population Between 2011 and 2023, in 2023, 45.2 percent of physicians surveyed experienced at least one symptom of burnout. When compared to other professions, 82% of physicians experience more of the potentially debilitating symptoms.

Advances in generative AI, such as ambient clinical documentation, significantly reduce administrative burdens and, as a result, help to decrease burnout. If your organization is ready to embrace this technological advancement, HealthTECH Resources provides expert healthcare AI implementation services. To discuss your specific needs, please connect with our leadership online or by calling our agency: (866) 826-1270.

The Traditional Scribe Role & Documentation Challenge

In conventional processes, a human takes notes before entering the data into the facility’s EHR application. This can become a time-consuming procedure as clinicians manually record information and spend time navigating through the EHR to enter the information appropriately. Not surprisingly, this task often spills over into after-hours charting. As this process takes up more time and energy, less time can be spent in direct patient interaction, which contributes to the development of the burnout referenced earlier.

As confirmation, JumpMD.com collected burnout-related statistics from a variety of industry studies, noting how administrative burdens, including navigation of EHR systems, serve as major physician burnout causes. As burnout accumulates, patient safety is lessened by as much as 7% to 10.6%, calculated by monitoring the number of significant medical errors.

What Ambient AI Scribing Involves

A microphone positioned in the room where doctor-patient consultations occur or embedded into a device will “listen” to what’s being said. Using speech recognition and natural language processes, the AI application creates a draft version of medical notes that follow the SOAP (subjective, objective, assessment, and plan) format. The clinician can then review and, as needed, edit the generated material that can then be integrated into the EHR system. Key technology components involved include speech-to-text capabilities, large language models, meaning, machine learning taking place on an enormous amount of text to enhance natural language processing and generation, entity extraction, and clinical coding.

Real-World Adoption & Evidence

Ambient clinical documentation implementation is already occurring in healthcare systems, including the following:

• In a pilot program, Mass General Brigham recorded about 500 visits with approximately 90 percent of system-drafted notes remaining in the final clinician ones, demonstrating high rates of accuracy. Originally, the hospital system planned to include 400 clinicians in the next phase, but because such significant interest existed, this phase involves 800 of them.
• Mayo Clinic and Ardent Health Services both gradually performed ambient clinical documentation implementations. Once Ardent saw 90 percent usage of the AI tools, they went to a full rollout. This was the first tool rollout, the CEO notes, with 100 percent satisfaction recorded by users.
• Approximately 200 University of Chicago Medicine doctors used this tool during a three-month pilot. Afterwards, 90 percent of clinicians said they could give patients their undivided attention, something that only 49 percent of them said before the ambient clinical documentation implementation pilot program.

The American Medical Association reported on the results of The Permanente Medical Group’s 2.5 million-plus encounters with AI scribing, and “they paint a compelling picture of how AI can help restore the human side of medicine.” They estimate that 15,791 hours of documentation time was saved, which equals 1,794 eight-hour days—while improving interactions between doctors and patients along with boosting physician satisfaction.

According to Ambient Documentation Technology in Clinician Experience of Documentation Burden and Burnout, published at the JAMA Network, survey results from 1,430 clinicians from Mass General Brigham and Emory Healthcare showed how this AI tool reduced burnout and improved scores of well-being.

Benefits for Health Systems & Clinicians

As alluded to in the real-world use cases, healthcare AI implementation of scribe technology:

• Reduces time spent on documentation and after-hours work
• Allows clinicians to place more attention on the patient and less on the keyboard
• Improves clinician satisfaction with potential for better retention
• Provides avenues to standardize and improve note quality and coding accuracy
• Offers scalability and cost-efficiency for large health systems

Risks, Challenges & Implementation Considerations

Issues to consider include the accuracy of drafts generated. Potential risks could include the AI misinterpreting spoken content, missing important context, and/or incorrectly generating note content. Privacy/consent issues can also arise as the application captures audio clinician–patient interactions; healthcare organizations will need to dedicate resources to data security and ensure that procedures dovetail with HIPAA compliance.

As with any change, this healthcare AI implementation will require workflow adjustments, clinician buy-in (which can be aided by professional change management services), training programs, customization of note templates, and integration with EHR systems.

ASCO Publications details potential regulatory, legal, and liability considerations. For example, who is responsible for the consequences if an AI-generated note is incorrect? The clinicians? The hospital system? The AI manufacturer? The broad conclusion listed notes how the “basic principles of tort law would likely apply, but the precise scope of the liability risks for each actor is determined by a number of factors.” As with any new technology, case law will need to be established.

Finally, during these early adopter stages, operational ROI uncertainty exists as system-wide efficiency/financial gains are still emerging. The Peterson Health Technology Institute acknowledges emerging positive impacts on burnout, reduced cognitive load, quality of clinical note summaries, and a more positive patient experience. However, financial factors still have mixed results to date. PHTI+1

The Evolving Role of the Scribe and Healthcare IT Consulting Implications

The role of the scribe is changing, from human-only to a hybrid model with AI and human oversight, and it’s important to make optimal decisions for your healthcare organization. This often involves a partnership with the right healthcare AI consulting firm so that your organization can get quality guidance on ambient AI documentation solutions, vendor selections, workflow redesign, integration, training, and governance.

As part of your healthcare AI implementation services, you will likely need consulting services from professionals with a range of expertise: developers, informaticists, change management specialists, data governance experts, and so forth. As you make your decisions, strategic considerations will include selecting mature vendors, aligning with your EHR system, ensuring high-quality documentation, measuring impact (on burnout, note turnaround, patient access, patient satisfaction, and so forth), and securing ongoing ambient clinical documentation support as needed.

Implementation Roadmap and Best Practices

Broken into stages, the process can look like this:

• Assessment: Evaluate current documentation burdens, workflows, EHR note completion metrics, and the amount of after-hours work.
• Pilot & vendor selection: Choose a small pilot site and evaluate multiple ambient AI scribe solutions.
• Workflow redesign: Map clinician encounters, include consent processes, define, review, and edit steps, and integrate the technology into your EHR.
• Training and change management: Involve clinicians, scribes, coders, and HIM staff and provide them with engaging educational programs.
• Metrics and monitoring: These can include clinician documentation time, burnout surveys, note quality, throughput, and after-hours time differentials.
• Governance and continuous improvement: Provide feedback loops to vendors, make customizations, verify audit note accuracy, and ensure compliance.

Future Outlook

Predictions include broader adoptions across specialties, tighter EHR integration, specialty-specific models, cost/ROI clarifications, and a move beyond note generation toward decision support. The role of AI will continue to grow by also supporting documentation for non-physician clinicians and team-based care.

In this pivotal development stage, HealthTECH Resources and our healthcare AI implementation services teams will remain at the cutting edge. This will involve monitoring the vendor landscape and regulatory changes, gathering new evidence as more studies take place, and watching for models with the best interoperability.

Ambient clinical documentation powered by AI is much more than a productivity tool. Instead, it’s reshaping how documentation is performed today, enabling clinicians to spend more time with patients and less time with data entry, freeing up the scribe concept in flexible, productive ways.

Contact HealthTECH Resources

Now is the time for healthcare systems to assess their documentation workflows, consider ambient AI scribe pilots, and choose the best partner for ambient clinical documentation implementation and integration, along with change management and governance. With proper implementation and oversight, ambient AI scribes are a strategic enabler for the future of clinical documentation—and HealthTECH Resources and our ambient clinical documentation support professionals are well-positioned to guide the journey.

To start the conversation about how healthcare AI consulting can help your organization, please reach out online or by calling us at (866) 826-1270.