AI Scribes
Many physicians are adding AI scribes to the digital tools in their practices. Â Evaluations and anecdotal comments from physicians indicate AI scribes contribute to a reduction in administrative burden, cognitive load, and after-hours work; improved efficiency and documentation practices; increased job satisfaction and work-life balance; and perceived improvement in quality of care.
What is AI Scribe?
AI scribes are digital tools designed to automate the administrative tasks of documenting patient encounters. They record, transcribe, and then summarize real-time verbal conversations with patients into (Subjective, Objective, Assessment and Plan (SOAP) notes or another template. AI scribes can then prepare referral letters and instructions for the patient, thereby reducing the time physicians spend documenting patient encounters and preparing follow-up tasks. Advanced AI scribes can extract content from transcripts and apply it to appropriate fields of an electronic medical record (EMR) in a structured manner.
What are the benefits of using AI scribes?
- Save time and increase productivity by minimizing the burden of administrative tasks and other documentation.
- Focus on patients, not on the computer screen. When physicians are not distracted by notetaking, there is potential for better observations and more thorough assessments, resulting in improved patient encounters.
- Improve accuracy of documentation details during patient visits. Some research shows an 85-90% improvement in documentation quality compared to manual entry. This ensures that patient records are precise and complete.
- Reduce administrative workload. AI scribes can ease stress and improve work-life balance for doctors.
What are the challenges with using AI scribes?
- Inaccuracy, often referred to as hallucinations, do occur. This may include misinformation, misinterpretation, misspellings, missed words or inserted text that was not spoken. AI scribes that are more mature are less likely to have hallucinations.
- Context and nuances in speech. While AI scribes can transcribe words accurately, they might miss the subtleties of meaning or emotion conveyed in the conversation.
- Accents and Dialects can be difficult for AI scribes to understand and require extra time to review the transcript or SOAP by the physician.
What are the guidelines for using AI Scribe from CPSNL and CMPA?
CMPA has information on privacy and security requirements on its website.
CPSNL has Practice Guidelines for AI scribes as of March 2025.
CMPA Webinar
What to consider when selecting an AI Scribe
- Real-Time Transcription – does the solution show real-time transcription of the physician-patient conversation?
- Detailed Notes – does the solution generate detailed medical notes covering the full clinical information of the patient visit, and easily format them as SOAP notes?
- Pause Transcription – does the solution allow for the physicians to pause and restart without losing data?
- Background Noise Filtering – does the solution filter out background noise?
- Note Templates – does the solution have more than one notes template (e.g., SOAP, referral, consult, summary)? Can the physician create or modify note templates to preferences or requirements preferred?
- Editing Options – can the transcript and notes be edited by dictation or keyboard?
- Language – does the solution recognize more than two speakers? Does it recognize multiple languages and diverse accents, slang, and clinical acronyms common in health care, capturing nuanced language used in clinical interactions?
- Visit Summaries for Patients – Does the solution generate a patient-friendly visit summary and instructions?
- Integration with EMRs – how are the AI scribe notes included in the Electronic Medical Record, such as through copy-paste functionality?
- Quality Assurance – does the solution assess and improve transcription accuracy and reliability, adapting to new language patterns and technological advancements?
- Personalization – does the solution allow for personalization? Does it learn your preferences?
Privacy and Security Requirements
Privacy and security are always a concern when personal health information is collected or stored. When selecting an AI scribe, consideration must be given to whether the solution meets Canadian legislative requirements.
Other privacy and security considerations include:
- Risk Assessments – what risks assessments, such as privacy risk assessment, threat risk assessment, penetration testing, has the vendor conducted, and were these assessments conducted by an independent third party?
- Data Residency – how much data does the vendor collect as part of the recording and/or transcribing? Does the vendor store and process all data within Canada? How long do they retain any data, including metadata?
- Audit Logs – where do the audit logs reside, who has access to them, and how long are they retained?
- Configurable Data Retention Period – who sets the retention period for the recording and transcription? Can the physician make changes to the retention period?
- Access Credentials – who has access to the recording or transcription? Who sets the criteria for who has access?