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Automate Session Notes

With the help of artificial intelligence (AI), emerging technology is alleviating a recurring point of contention for medical professionals: how should a patient’s clinical session be documented? This subjective question often generates with hundreds of different responses from clinicians in various medical fields. So, what if you could rely on accurate AI technology to automate the process for you?

That’s exactly what Dr. Robert Budman, the Chief Medical Information Officer (CMIO) for Nuance Communications Healthcare Division, talks about in this video interview with Ray Barrett from the Telehealth Certification Institute. In this interview, you’ll understand how AI has revolutionized approaches to medical documentation. Dr. Budman shares how Nuances’ Dragon Ambient Experience (DAX) technology, a complex AI neural network with millions of lines of code, ensures “tremendous accuracy for [automating] notetaking.”

With ambient clinical intelligence technology, subjective diagnostic and treatment decisions are now more objective than ever. Clinicians are investing in technology to reduce their error rate and prioritize the patient experience. Ambient AI technology is especially useful for optimizing patient rapport. For clinicians who have a large patient load and may not remember every unique detail about a patient’s personal life, DAX can help recall client details later to personalize future visits. DAX is so advanced that it can even detect when a physician says a joke and separates this statement from relevant clinical material.

Though it was first used in orthopedic settings, DAX is now used across medical specialties and is easily adaptable to telehealth or telemedicine sessions. Dr. Budman emphasizes that the “huge healthcare footprint” established through years of AI development has given Nuance an opportunity to branch into “virtually every outpatient specialty.” Dr. Budman estimates that AI for the behavioral health field will likely be released in the next year to 18 months.  

Healthcare providers also frequently cite safety and security concerns for sensitive patient information as a top priority when investing in technology. Luckily, DAX is “HIPAA secure,” de-identifies patient information, and stores conversations for three years in the cloud. Dr. Budman says that an acquisition from Microsoft, and the merging of two massive engineering teams, have supercharged Nuance’s innovation.

Dr. Budman recommends organizations that are interested in learning more about DAX or ambient clinical intelligence technology should consider conducting an internet search and visiting Nuance.com to see if this type of tech is right for them.

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Dr. Robert Budman, MD MBA ABFM ABPM, is board certified in Family Medicine and Clinical Informatics. His background includes academic medicine at UC-Irvine, emergency medicine, hospitalist work, worker’s comp, urgent care, utilization review, clinical documentation improvement (CDI), and of course family medicine. He has created content for multi-state IDN’s, worked on quality initiatives with major hospitals, re-engineered several EHR modules, and has a passion for workflow improvements for provider and patient care needs.

In the Nuance Communications Healthcare Division, Dr. Budman supports computer-assisted physician documentation and clinical documentation improvement (CDI) efforts; engages directly with physicians, executive leadership, and front-line providers; and he works directly with revenue cycle and IT teams. Dr. Budman focuses on applying Dragon to documentation efforts and adding artificial intelligence tools to assist providers with creating their best possible notes while targeting diagnostic coding, improving billing, and alleviating EHR burdens.

By: Michael Tugendhat

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