Some doctors are using AI to jot down medical records. What do you have to know?

Imagine this. You have finally worked up the courage to see a GP about an embarrassing problem. You sit down. The GP says:

Before we start, I enter my appointments on the pc. This is AI – it writes a summary of the notes and a letter to the specialist. Is that OK?

Wait a minute – an AI that writes our medical records? Why would we wish that?

Records are essential for protected and effective healthcare. Doctors must keep good records to keep their registration. Health services must good record-keeping systems to be accreditedRecords are also legal documents: they will be necessary in insurance claims or court proceedings.

But writing things down (or dictating notes or letters) takes time. During appointments, doctors can let their attention veer between good documentation and good communication with the patient. Sometimes doctors should work on notes after work, at the tip of an already long day.

So there’s comprehensible excitementfrom every kind of medical professionals, via “ambient AI” or “digital scribes”.

What are digital writers?

This isn’t old-school transcription software: dictate the letter, the software types it word for word.

Digital writers are different. They use AI – large language models with generative capabilities – much like ChatGPT (or sometimes GPT4 himself).

The application silently records the conversation between doctor and patient (via the microphone of a phone, tablet or computer or via a special sensitive microphone). The AI ​​converts the recording right into a word-for-word transcript.

The AI ​​system then uses the transcript and the instructions contained therein to jot down a clinical note and/or letters for other clinicians to review.

Most doctors know little about these technologies: they’re experts of their field, not in AI. The marketing materials promise: “Let AI manage your medical records so you may spend more time along with your patients.”

Put yourself within the doctor's shoes. You might say, “Yes, please!”

How are they regulated?

Recently Australian Health Professional Regulatory Authority has issued a code of conduct for using digital scribes. The Royal Australian College of General Practitioners published an information sheetBoth indicate to the doctors that they continue to be chargeable for the contents of their medical records.

Some AI applications are regulated as medical devicesbut many digital scribes are usually not. Therefore, it is usually as much as health services or clinicians to find out whether scribes are protected and effective.

What does research say to date?

There may be very limited data or practical evidence on the performance of digital writers.

In a big Californian hospital system, researchers followed 9,000 doctors for ten weeks in a pilot test of a digital author.

Some doctors were comfortable with the scribe since it reduced their working time and allowed them to speak higher with patients. Others didn’t even start using the scribe.

And the recorder made mistakes – for instance, recording an incorrect diagnosis or noting that a test had been performed when it must have been done.

So what should we do with digital writers?

The Recommendations of the primary Australian National Citizens’ Jury on AI in Healthcare reveal what Australians expect from AI in healthcare and supply a superb place to begin.

Building on these recommendations, listed here are some things to think about regarding digital recorders during your next visit to a clinic or emergency room:

1) You ought to be told when a digital recorder is used.

2) Only writing instruments designed for medical care could also be used in healthcare. Traditional, publicly available generative AI tools (corresponding to ChatGPT or Google Gemini) mustn’t be utilized in clinical care.

3) You should have the opportunity to consent or refuse consentfor using a digital recorder. They ought to be informed of all relevant risks and have the opportunity to freely consent or refuse.

4) Clinical digital scribes must adhere to strict data protection standardsYou have a Right to privacy and confidentiality in your health care. The entire record of an appointment can contain way more detail than a clinical note would normally contain. So ask:

• Will your appointment transcripts and summaries be processed in Australia or one other country?
• How is their security and confidentiality ensured (for instance, are they encrypted)?
• who can access it?
• how are they used (for instance, are they used to coach AI systems)?
• Does the author access other data out of your dataset to create the summary? If so, is that data ever shared?

Is human supervision sufficient?

Generative AI systems could make things up, make mistakes, or misunderstand a patient's accent. But they often communicate those mistakes in a way that sounds very convincing. This means careful human review is crucial.

Doctors are told by technology and insurance firms that they have to review every summary or letter (and they have to). But that's not the case. really easyBusy clinicians may rely too heavily on the scribe and easily accept the summaries. Tired or inexperienced clinicians might imagine their memory should be fallacious and the AI ​​should be right (referred to as automation bias).

Some have suggested These scribes also needs to have the opportunity to create summaries for patients. We don't own our own health records, but we often have the suitable to access them. Knowing that a digital scribe is in place can increase consumers' motivation to have a look at what's of their health record.

Clinicians have at all times kept notes about our embarrassing problems and have at all times been chargeable for those notes. The privacy, security, confidentiality and quality of those records have at all times been necessary.

Maybe sooner or later, digital scribes will lead to raised records and higher interactions with our doctors. But for now, we’d like good evidence that these tools work in real clinics without compromising on quality, safety or ethics.