GenAI for Documentation Helps Lee Health Physicians Add One More Patient Every Day

Medical documentation by practicing physicians has been a challenge since the creation of the medical record. Dr. Will Carracino, chief medical information officer at Florida-based nonprofit health system Lee Health, recalls struggling to keep up with documentation throughout his years of practice, starting from the first day he became a physician.

THE PROBLEM

“It’s a challenge to put into the chart exactly what the patient is feeling,” Carracino explains. “When I was in practice, I bought a really fancy fountain pen to entice myself to spend more time charting, convincing myself that I would enjoy charting more with this addition.

“Physicians value the time they spend helping and supporting each patient individually,” he continued. “Keeping records takes up a lot of time, which eats into the limited time a physician has in the office with patients. The process also impacts the quality of the patient-physician interaction. Taking notes, often on a computer, can be distracting and intrusive for both the physician and the patient.”

Although the process can be taxing at times, clinical documentation is an essential part of the role of a practicing physician. It is the record of the patient experience. The information and summary provided, and accessible to the patient, supports the improved health and well-being of each individual.

PROPOSAL

“Historically, we’ve looked at different solutions for medical documentation,” Carracino noted. “An opportunity using generative AI as a solution that could improve the patient and physician experience together. Previously, using human transcription was a tested solution, but this option proved to be both costly and prone to human error.

“We started doing speech recognition and natural language processing more than a decade ago,” he continued. “The first iterations were cumbersome. I always explained that natural language processing is like training a spouse. There are things you can change over time, but other things you just have to work within the structure of the relationship.”

According to him, generative AI would require less training, would allow the doctor to communicate with the patient again without the technology disrupting the conversation, and would free up valuable time for both the patient experience and personal opportunities, helping to prevent burnout.

TOOK UP THE CHALLENGE

According to Carracino, the new generative AI functionality is a game changer.

“Just by having a listening device in the room after the patient gives consent, the conversation is like a coffee shop conversation, but with medical concerns,” he explained. “The days of the patient watching the doctor tap away at a keyboard to record their experience are over. The Artificial intelligence focuses on medical issues, extracts the social details, and organizes the note into an easy-to-read, well-formatted medical document.

“We started with a pilot group of 20 providers,” he continued. “The provider profile included internal medicine, cardiology, pain management and pediatrics. Our plan was to find providers who were able to use new technology but also had the potential to improve their document time or patient throughput.”

Lee Health’s AI transcription technology, Abridge, seamlessly integrates into the Epic electronic medical record. Providers find the process much less burdensome than previous documentation techniques.

RESULTS

Lee Health is still validating the exact outcome data, but Carracino outlined five favorable results so far:

• Improved note completion, now same day for over half of clinicians. Improved provider efficiency and satisfaction; this is essential to supporting providers and combating burnout. Based on the pre/post survey questions from the pilot group, 74% of clinicians spent less time working outside of work hours, which improved provider satisfaction and work-life balance.

• 86% of physicians now feel they have enough time to document. Lee Health is monitoring the impact of this to improve patient access by allowing providers to add an additional patient per day to their schedule. This allows patients to schedule more quickly, already adding an average of two patients per week. With time to document during their regular work hours, physicians can get their work done.

• Reduced documentation errors. Improved charting time enables clinicians to enter detailed and accurate patient information, reducing the chance of errors.

• Patients benefit from more attentive care and detailed consultations, leading to higher overall satisfaction with their care experience.

• Lee Health anticipates improvements in physician retention rates. With lower burnout, fewer physicians feel the need to leave the profession, helping to maintain a stable and experienced medical workforce, further contributing to the overall quality of care. This improvement in workflow efficiency allows physicians to maintain a better work-life balance, reduce stress, and improve job satisfaction.

ADVICE FOR OTHERS

“I don’t think anyone can deny that Generative AI is going to transform healthcare in our country,” Carracino said. “The question is, how can we do this in a safe, productive, and effective way?

“We have an AI governance committee at our organization, and it’s made up of both operational and clinical leaders,” he advised others. “The committee looks at the value of implementing new technology and capabilities to analyze what it can offer the patient and the provider.”

While each product has a purpose, not all of them align with Lee Health’s mission and vision as a healthcare system.

“This is going to be an exciting part of our medical history and we must embrace it appropriately, with the exciting vision it deserves, and by using our classic techniques for product evaluation for value and safety,” he concluded.

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