Clinical record keeping is generally a key component of a competent medical practice and is essential to practitioners seeking payment from Medicare for services and products rendered to beneficiaries. As we have all observed, Centers for Medicare & Medicaid Services (CMS) and its contractors frequently deny legitimate Medicare claims for allegedly incomplete or inadequate documentation. Documentation failures can be attributed to a variety of causes, including technological limitations, insufficient education or training, overworked clinical staff, the absence of adequate documentation protocols or simple human errors due to fatigue or distraction.
Preparing good medical record documentation, however, is time consuming and burdensome. Many studies show that recordkeeping is a key source of physician burnout. Further, the widespread use of electronic health records (EHR) has arguably made the problem worse in some respects. Over the years, many “solutions” to the problem of medical recordkeeping have been explored with varying degrees of success. Fortunately, the advent of artificial intelligence (AI) tools may be the most promising of all solutions offered to date. For example, the Permanente Medical Group, a member of the American Medical Association’s (AMA’s) Health System Program, recently offered one possible solution: ambient augmented (or is it artificial?) intelligence.
This ambient AI tool applies a combination of machine learning, data analytics and language processing to clinical conversations to produce scribe-like capabilities in real time. The primary goal of Ambient AI is to reduce the provider’s documentation burdens while enhancing the value of face-to-face patient encounters. In short, this technology uses a smartphone microphone to transcribe patient encounters as they occur, without retaining audio recording of the encounter. The tool summarizes the conversations’ clinical content and produces a note documenting the visit. Interestingly, the tool works to filter out irrelevant, purely personal exchanges between the provider and patient, leaving only the essential – but complete – clinical information.
The Permanente Medical Group recently offered this technology to physicians practicing in Northern California and asked them to submit feedback. Providers attended a one-hour training and were instructed to provide a one-page handout to patients, who were then asked to give informed consent for the doctor to use the tool during their visit. The technology was used on a trial basis by 3,442 physicians in more than 300,000 patient encounters over a 10-week period. Providers largely praised the new tool, specifically recognizing:
(1) Accuracy – The encounters were transcribed accurately and required relatively minimal editing of the AI after each visit.
(2) Less provider burden – Reduced time spent documenting clinical encounters generally.
(3) Ease of Use – A one-hour training was all that was required to employ the technology, and many providers described it as intuitive.
(4) Privacy – No audio recording is maintained, and no patient data is fed to the tool beyond the verbal conversation itself.
Interest in ambient AI to aid in clinical record-keeping extends well beyond the Permanente Medical Group. Last year, more than two-thirds of the 1,100 physician respondents in an AMA survey indicated perceived advantages to using AI in their health care practice. In November 2024, the AMA developed and published key principles to address the development and use of similar tools in health care. (AMA Principles for Augmented Intelligence Development, Deployment, and Use.)
The tool is being closely monitored and continually refined. Providers must give careful attention to their records to ensure the technology is accurately and reliably supporting their practice. The AI scribe is meant to enhance a provider’s ability to maintain accurate records, not replace the provider entirely. Physician editing will still be required to some degree, because while most of the clinical notes produced in the Northern California trial were accurate and complete, a small percentage contained what the industry calls “hallucinations.” On one occasion, a physician mentioned scheduling a prostate exam, but the AI scribe recorded that the exam had already been performed. In another case, the conversation between the doctor and patient referred to the patient’s hands, feet and mouth; the AI summary indicated the patient had been diagnosed with hand, foot and mouth disease.
This new and rapidly-evolving technology will likely assist providers across all disciplines. It may be particularly useful for providers who regularly treat Medicare beneficiaries. Given the robust record-keeping requirements placed on practitioners by CMS and its contractors, ambient AI scribe technology may be a valuable tool to efficiently capture the clinical data essential for payment of subsequent Medicare claims. Providers should strongly consider the use of AI tools to see if “augmented” intelligence will improve their record-keeping.
Alex Roll is an experienced litigator and member of the firm’s healthcare and litigation practices. He provides strategic advice to achieve his clients’ objectives with efficiency and clarity. To discuss this or related issues with Alex call (208) 562-4900 or send an email to aroll@parsonsbehle.com.
