AI scribe value-based care enterprise Navina has published preliminary data demonstrating that the inclusion of patient history in ambient scribe technology helps to advance the quality of documentation more significantly.
In her study, Navina discovered that the use of historical context led to better documentation by 18 percent. It also raised the completeness score of the clinical note to 82.9 out of 100, where the score was 40.4.
It implies that ambient scribes themselves are not sufficient to provide enough background to save physicians the time to scavenge patient records in the past and accurately reflect the complexity of chronic illnesses.
Navina measured documentation quality using a subset of the QNOTE clinical note documentation quality instrument, and it measured completeness on a 100-point scale. The study is yet to be vetted by the peer review process and is now in preprint on medRxiv.
According to Yair Lewis, the chief medical officer of Navina and himself a practicing physician, conversations between physicians and patients may not always cover what should be remembered when analyzing the patient. A patient encounter does not involve the sharing of information such as specific lab values and dates, he said.
Navina provided 354 primary care encounters in diabetic and hypertensive patients. The two common conditions form the proxy of all the chronic conditions in the study.
According to Lewis, the absence of any relevant medical information in the documentation may affect the quality of care down the line, and the technology of the ambient scribe could have financial consequences in terms of value-based care arrangements and may not be efficient in saving time on the part of the doctors.
The study adds that it is impossible to document every important aspect of chronic conditions without the complete clinical history of a patient, including their labs, comorbidities, medications, and preventive care. These omissions have the potential of affecting the quality of care, overloading physicians, and decrease the accuracy of reimbursements.
Patient context has been added to the products of many large AI scribe companies. Nabla has a patient summary agent that forms a patient summary pre-visit. Abridge promotes the context of electronic health records and a predicted problem region of its clinical note generation technology. Suki has a pre-visit summary and a question and answer feature with the medical history of the patients to locate the information. Ambience presents the history of patients, their labs and notes, as well as provides an AI copilot to be communicated with by the clinician.
Most of the time, what occurs is that the ambient summary will be taken by the doctors but then manually changed by comparing with the record and then adding the corresponding parts of information he/she need, Lewis said.
Although AI scribe firms are on this path, the EHRs do not easily extract data, as Lewis described. He provided that provider organizations ought to deliberate on what components of the EHR information a vendor can access, whether they are linked to health information exchanges, and how patient history can be integrated with the eventual clinical documentation.
The AI technology developed by Navina reveals the past medical history of the patients to the care provider in real-time. It collaborated with the ambient scribe company Nabla in July to introduce AI scribing to its platform.
In the future, Lewis said, the company would like to expand the study to thousands of encounters that study several diverse chronic illnesses.
Lewis believes that the effect of the research will be simply another kind of headwind that will force more companies to work in the direction of it because it can now actually be semiquantified.
With Additional Patient Context, AI Scribe Output Improves in Quality and Completeness: Research
Recent research highlights a major advancement in digital clinical documentation: the AI scribe becomes significantly more accurate and complete when provided with enhanced patient context. This includes medical history, current medications, chronic conditions, lab trends, and social determinants of health.
