Ask Dr. Wellis: Automating clinical documentation - physicians' point of view

🔄 Reminder: Dr. Wellis is an AI-powered physician GPT I’ve developed to assist with planning and implementing tech and AI projects in healthcare organizations.

Amir asks: OK, Doc, according to your recommendation, I decided to start with automating clinical documentation and data entry. What is the best way, from the physicians' point of view, to choose and implement an appropriate solution?

Dr. Wellis answer: Great choice! Automating clinical documentation can make a real difference in efficiency and physician satisfaction. From the physicians’ point of view, the best way to choose and implement the right solution involves a collaborative, step-by-step approach that ensures the technology aligns with their needs and workflows.

Here’s a recommended process to guide you:

1. Form a Physician-Led Working Group

• Start by creating a small team of physicians, nurses, and admin staff who are interested in using technology to improve documentation. They’ll help you understand daily pain points and act as champions for the new tool.

• Having physicians directly involved in the decision-making fosters trust and helps ensure the chosen solution meets clinical needs.

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2. Set Clear Objectives and Requirements

• Work with the physician group to define what they need most in a documentation tool. Consider:

  • Ease of use: Physicians need a tool that doesn’t disrupt their workflows or add steps.

  • Accuracy and quality of transcription: Ensure the tool has high accuracy in medical terminology.

  • Seamless EHR integration: The solution should ideally integrate with the hospital’s current EHR to reduce double documentation or the need to switch between systems.

    
    

3. Evaluate Multiple Solutions with Hands-On Testing

• Select a few reputable AI documentation tools and arrange for hands-on demos where physicians can directly interact with each tool.

• Encourage the physician working group to test specific workflows, such as transcribing patient histories or progress notes, to assess each tool’s functionality and usability.

• Look for solutions that offer natural language processing (NLP) with medical context understanding, ensuring they can handle the specific language and structure of clinical documentation.

  
  

4. Run a Pilot Program with Real Clinical Scenarios

• Implement a small-scale pilot in one department (like internal medicine or cardiology) to see how the tool performs in real patient care settings.

• During the pilot, gather continuous feedback from physicians on what’s working and where improvements are needed. This helps identify any adjustments required for a wider rollout.

  
  

5. Provide Training and Ongoing Support

• Offer training sessions for physicians and ensure support is available during early use to answer questions and resolve issues quickly.

• Consider appointing “superusers” from the physician working group who can support their colleagues and champion the technology’s benefits.

  
  

6. Track and Share Success Metrics

• Measure success by tracking metrics that matter to physicians, such as time saved on documentation, reduction in errors, and overall satisfaction.

• Share positive results hospital-wide to demonstrate how the tool has improved workflow and patient care.

  
  

7. Gather Feedback and Refine the System

• Continue collecting feedback even after implementation to ensure the solution remains effective and aligned with evolving needs.

• AI tools often have updates and customizations; stay in contact with the vendor to adjust the solution as required.

  
  

This approach will make the transition smooth for physicians and increase the likelihood that they’ll see AI as a positive, efficiency-boosting tool. Let me know if you’d like to explore specific solutions, or if you need help drafting communication for the pilot rollout!