What are some of the latest trends or innovations in clinical documentation?

AI can be helpful in generating ideas, but it's important to understand its limitations. For example, AI might not always cite references correctly. In my experience, AI has even created false references to the medical literature that do not exist. I've found AI to be especially useful as a brainstorming tool, helping me to clarify the questions I want to ask and ideas that I want to develop. These are the same ways that AI can be used as a clinical documentation and coding tool.

I think this is a great idea to incorporate into the EHR. However, there are a few important issues to keep in mind: 1. Patients may misinterpret a past diagnosis, so it's important to verify. For instance, did they have an MI, or was it just chest pain? 2. Symptoms such as "flutter" can be misinterpreted as a diagnosis, so it's important that the software does not extract data without context. 3. Biometric data needs to be reviewed by a physician before being entered into a chart. The apps can misinterpret artifact as arrhythmia, leading to an inaccurate diagnosis. Bottom line: PGD can be useful, but must be verified for accuracy and reviewed for clinical significance by the physician. Otherwise this "time saving" method may cause harm.

In the last 10 years , I can’t point to an innovation in clinical documentation that has improved workflow. That’s why administrative burden is cited as one of the top reasons of provider burnout. NLP and speech to text shows promise,but both are very early. True innovation in clinical documentation should allow us to focus on the patient, not the chart. Im still waiting.

We should prioritize patient and family wellbeing as new techniques are developed (as well as clinician wellbeing). Or at least we should assure that “improvements” don’t reduce everyone’s wellbeing. Having a scribe (in person, remotely or via AI) would be the most helpful so that the clinician can focus on the patient.

The clinical documentation burden on physicians is no joke and the most immediate remedy is a Medical Scribe. While current trends in AI will eventually take over the profession, the benefit of in-person human scribes is undoubtable (at least for now). It’s no secret that most scribes are pre-medical or pre-PA students that use the position for experience and knowledge building. My personal experience as a Scribe has been fantastic and I worry that students in the future won’t be able to have a similar experience due to AI takeover.

Cost! My experience with HR and computer documentation is that it actually increases time for the clinician,reduces reliability (perpetuates errors and bias) and has not been proven to improve outcomes.