AI tools offer opportunities for physicians, with some important considerations to keep in mind
When physicians describe the administrative tasks that weigh them down, summarizing conversations with patients into detailed medical notes is often at the top of the list.
Given that they address a common pain point for primary care providers and specialists, it’s little wonder then that digital scribes are being adopted as an early-use case of artificial intelligence (AI).
AI scribes can capture and summarize conversations between the physician and the patient and families. Summarizing clinical encounters in real-time allows for rapid documentation of regular clinic appointments, new consultations, inpatient progress notes, family meetings and other updates to the medical records. The use of scribes frees physicians from such administrative tasks, meaning proportionally more time can be devoted to face-to-face patient interactions and other high value work.
You are ultimately responsible for ensuring that the medical note is a complete and accurate representation of the patient encounter.
And while the tool offers opportunities, important considerations must be kept in mind when using AI scribes in clinical care:
- Accuracy: If you use AI scribes in your practice, be aware that AI outputs may contain errors in documentation. Review the documentation for accuracy before accepting it as completed and ready to be included in the patient’s medical records or shared within the circle of care.
- Data privacy and protection: Your obligation to protect your patients’ personal health information (PHI) is no different when using AI tools than in any other circumstance. Ensure that the AI scribe you are using complies with the requirements of the Personal Health Information Protection Act and that patient PHI is protected, in line with the expectations of CPSO’s Medical Records Management, Medical Records Documentation and Protecting Personal Health Information policies.
- Transparency: Transparency between physicians and their patients is an important way through which a trusting relationship is built and maintained. Before making any recording of a clinical encounter using an AI scribe, obtain consent from the patient for the purpose of the recording. For example, ask the patient to consent to having the AI scribe “listen and summarize the conversation” for the purpose of medical documentation.
- Accountability: Carefully review all medical notes captured and summarized by AI scribes to prevent inaccurate or misleading information from being entered into the patient’s medical record. You are ultimately responsible for ensuring that the medical note is a complete and accurate representation of the patient encounter which will allow anyone in the patient’s circle of care to provide appropriate follow-up care.
As with any new clinical tool, it is important that physicians keep patients’ best interests top of mind when adopting AI in their practice. For more information, see CPSO’s new Advice to the Profession: AI Scribes in Clinical Practice document.
