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ADVICE TO THE PROFESSION: AI SCRIBES IN CLINICAL PRACTICE

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Artificial intelligence (AI) technology is rapidly evolving and expected to improve health care and the way it is delivered. In particular, the use of AI scribes has the potential to alleviate physician burnout and reduce time spent on clinical documentation. This Advice to the Profession document discusses some of the benefits and outlines key considerations physicians should keep in mind when using AI scribes.

What is an AI scribe?

An AI scribe is an AI-powered tool that automatically captures and summarizes (and, in some cases, records) clinical encounters between a physician and a patient into detailed medical notes for the physician’s review in real-time.

AI scribes can be very helpful in alleviating some of the administrative burdens that physicians face, allowing them to focus on direct patient care while supporting more accurate record-keeping.

How does an AI scribe differ from dictation software?

Dictation software simply converts voice to text, while an AI scribe can extract content from what it summarizes and apply it to appropriate fields of the patient’s medical record. More recent AI scribes have the capability to analyze and isolate relevant medical information from the conversation between a physician and patient, and create a more concise medical note for the physician’s review.

Can I use AI scribes in my practice?

Yes. However, when integrating AI scribes into their practice, physicians should be aware of the following:

  • Accuracy: AI scribes can create medical records containing errors. Physicians need to review all information summarized by the AI scribe for accuracy and completeness.
  • Accountability: physicians are ultimately accountable for everything that is captured in the patient's medical record.
  • Data privacy and protection: all patient data entered into the AI scribe needs to be kept private and secure. Physicians’ obligation to protect their patients’ personal health information is no different when using AI scribes than in any other circumstance.
  • Transparency: physicians need to inform patients about how the AI scribe will be used for the purposes of documentation, and in particular obtain patient consent before recording conversations using AI scribes.

Physicians using AI scribes to assist with documentation need to be mindful of existing legal and medical professional obligations which would also apply to the use of AI scribes1. Physicians may want to consult the Canadian Medical Protective Association (CMPA) or the Ontario Medical Association (OMA) for further guidance on the use of AI scribes.

Endnotes

1E.g., Personal Health Information Protection Act, 2004, and CPSO policies including Medical Records Management, Medical Records Documentation and Protecting Personal Health Information.