AI Technology and Consent Information

Artificial Intelligence (AI) may provide efficiency, accuracy and a cost-effective approach to healthcare providers documentation; however, there are several factors to consider and be aware of prior to implementing AI technology in your practice. 

What is AI?

Artificial Intelligence. AI in healthcare for the purpose of enhancing and improving documentation is growing swiftly. AI is the ability of a machine to perform cognitive functions that normally are performed by the human mind. AI is powered by highly developed speech recognition and natural language processing algorithms to assist healthcare providers to streamline administrative tasks, documentation burdens, and help enhance patient care. It can lead to more effective communication through maintaining direct eye contact, allowing more engaged conversations and fewer distractions from taking the time to document manually during the exam process.

Key Points to Successful Implementation of AI: 

• Preserving Confidentiality and Data Security - ensure that you implement strict data encryption protocols and preserve sensitive medical data. 
• Obtain Informed Consent: Healthcare providers must ensure patients, as well as individuals accompanying the patient, are informed about the use of AI scribes during the medical visit. Providing your patients with transparent communication regarding data processing, storage, and the driver for the use of AI transcription is essential to maintain patient privacy rights. Obtaining patient and guest consent is essential. 

• AI Scribing Consent Form

• Mitigation of Bias: Continuous monitoring and refinement of AI algorithms are essential to detect and mitigate biases that may affect the accuracy and fairness of transcriptions, particularly in diverse patient populations. 
• Human Oversight: While AI scribes automate the transcription process, human oversight remains critical for reviewing and editing transcripts to verify accuracy and completeness and ensuring the integrity of medical documentation. 
• Ensure protection of PHI and HIPAA compliance with this process. Legal and Regulatory compliance is essential if you are planning to utilize AI technology for documentation. Ensure you have a BAA agreement if the vendor has any access to the data for technical/backend purposes.  
• Clear documentation of AI scribing processes, policies and procedures, responsibilities, and legal implications helps mitigate potential liabilities and ensures accountability in patient care settings. 
• When implementing AI scribes, be sure to refer to your state laws regarding recording of conversations in terms of consent, exceptions and the use of the recordings.
• United States Recording Laws - Recording Law

Best Practices: 

• Integration of an AI system into your Electronic Health record that will provide a smooth and seamless transition.
• Training is imperative for implementing and utilizing AI technology. Staff need to comprehend and recognize the limitations of AI technology and be able to identify the need to utilize human intervention when needed. Accurate documentation is a crucial component of healthcare. When utilizing AI, maintaining the competence to recognize when it is best to revert back to manual documentation is vital.
• Quality Assurance Measures/Protocols should be implemented to ensure continuing accuracy and reliability of the AI-generated transcripts/documentation. 
• Providers need to review the patient encounter captured through AI and ensure accurate and precise documentation. Remember to date and sign all encounters

Please visit the Integris Group Cyber Portal site for more information on Ways to Improve Medication Safety in the Physician’s Office. For login information, please contact Jordin Longo at jlongo@integrisgrp.com.