Technologies for reducing documentation burden

The latest innovations can help you reclaim valuable time, but there are a few factors to consider.

Female Doctor reviewing computerized document management system.

Imagine not just reducing documentation burden, but eliminating it altogether. We're not there yet, but recent technological leaps and bounds hint at the tantalizing possibility. Choosing a medical documentation solution that's right for you comes down to personal preference, but it’s also about weighing the costs in money upfront and time spent using the system daily, plus any possible risks.

Medical scribes

Cost: $2,500-$4,500 per month

Medical scribes essentially serve as personal assistants to physicians, shadowing them, documenting visit notes and performing other administrative tasks. Medical scribes can increase efficiency, but they are hard to scale and may be too costly for private practices or individual health care professionals. They also may have limited medical backgrounds, and non-physician providers working with sensitive data can put physicians at risk of malpractice.

  • Pros
    • Delegating documentation and other administrative tasks to an in-person scribe takes burden off the physician
  • Cons
    • Not broadly used in family medicine or primary care due to costs and training required
  • Impact
    • Increased productivity; reduced documentation burden
    • 57% increase in patient face time
    • 27% decrease in EHR time

MORE: Medical scribe companies

Virtual scribes

Cost: $1,000-$1,200 per month

Virtual scribes and transcriptionists are less intrusive because there’s no third party in the exam room, but their usefulness is hampered by costs, note turnaround times, offshore data transmission and security risks.

  • Pros
    • Cheaper than medical scribes; no retention issues
  • Cons
    • Performs only patient charting
    • Not real-time; up to 24-hour delay
    • May incur added hardware costs
  • Impact
    • Up to 85% burnout reduction
    • 1.1 hour/day EHR time reduction
    • 1 hour/day documentation reduction

MORE: Virtual scribe companies

Medical speech recognition

Enterprise: $25-$75 per month
Single physician: $200 per month

Medical speech recognition (MSR) technology allows you to dictate your notes instead of typing. Dictation devices can help improve health outcomes and patient understanding of care plans, but they don’t fully relieve physicians of documentation burden due to the work they require to run at optimal levels.

  • Pros
    • Established technology option with greatly improved accuracy
  • Cons
    • Similar to dictation but physician must navigate EHR and edit
  • Impact
    • 79% of users were satisfied with MSR
    • 77% reported improved efficiency

Ambient speech recognition

Cost: $1,800 per month

Ambient speech recognition technology “listens” to a patient's and/or caregiver's conversations with the physician throughout the visit, including history and exam details, and works with an outside service to create a visit note.

  • Pros
    • Shows promise in decreasing documentation burden and enhancing efficiency
  • Cons
    • Ambient discussion in the exam room is personal; medical decision-making is purposeful and may not be done in the exam room
  • Impact
    • 79% of users reported better documentation quality
    • 70% saw reduced burnout and fatigue
    • 81% of patients saw greater physician focus

AI assistants

Cost: $150-$200 per month

AI-powered, voice-enabled digital assistants can help physicians complete documentation and other administrative tasks. Although AI assistants still have room to develop, they are the only documentation solutions on the market that show promise in totally automating the EHR documentation process.

  • Pros
    • Mobile assistant allows physician to step away from EHR and let assistant interact
    • Consumer-friendly features and cost
    • Some AI assistants use a "human in the loop" to edit and correct the transcription while the AI assistant learns
  • Cons
    • EHR integration is essential and vendors have been slow to support, but progress is being made
  • Impact
    • 72% reduction in documentation time
    • 40% decrease in after-hours work, including weekend work
    • 20% increase in practice satisfaction

Innovation Labs: Using an AI assistant to reduce documentation burden in family medicine

This AAFP Innovation Labs report provides evidence that using an AI assistant can significantly reduce documentation burden and family physician burnout.
Read the report

AI vs. medical speech recognition: What's the difference?

Unlike AI, legacy MSR systems did not leverage deep learning needed to perform voice-to-text conversion or have natural language understanding. Although newer MSR solutions have progressed in these areas, AI assistants better understand natural language and can detect intent (i.e., commands from the user). Whereas voice recognition solutions require the user to specify where dictation should be placed in the EHR note, AI assistants’ built-in model of documentation recognizes embedded commands and knows where to place text. This ability enables the physician to generate a note without having to navigate or edit in the EHR.