AI scribes are a technology solution that streamlines clinical documentation by transcribing a patient encounter to draft a structured clinical note automatically. This type of software is relatively new, and providers are still learning how best to incorporate scribe software and how to talk about it with patients.

Many physicians raise common questions: What are the ethical concerns? Do you need to obtain verbal consent to use an AI scribe during a visit? How should you discuss AI software with patients?

Let’s look at some helpful suggestions compiled from providers already using AI scribes for clinical documentation.

Are AI scribes HIPAA-compliant?

Before introducing new documentation technology into the clinic, you should confirm that it’s HIPAA compliant. AI scribe software companies are concerned about data privacy and security, but you should always confirm that developers are taking necessary precautions. 

Before bringing any software into your practice – including an AI medical scribe – consider asking the following questions:

  • What measures are in place to ensure HIPAA compliance?
  • How is patient data stored?
  • How is access to patient data controlled?
  • What is the process for data retention and disposal?

Software developers should have encouraging answers to these questions and will often post details on an FAQ page (here’s one example from Mobius MD). Protected health information should always be encrypted, and apps should have strong password security. Furthermore, trustworthy software companies will hire third-party auditors like HITRUST.

Ensuring HIPAA compliance is the first step toward helping you and your patients use AI scribe technology with confidence.

Once you’re confident your AI scribe is HIPAA compliant, the next question is consent. Most providers obtain verbal or written permission from patients before using an AI scribe for clinical documentation.

If you already have intake paperwork to obtain patient consent to transmit their PHI electronically, this may be sufficient for using a scribe. However, always seek professional legal advice if you’re not sure. 

Many providers also obtain verbal consent from patients at the beginning of a visit. Whatever approach you take, it is important to inform patients about AI’s role in their healthcare and obtain consent before using AI software for clinical visits. 

How to discuss your scribe with patients

Here are a few tips for asking patients for verbal consent to use an AI scribe for clinical documentation.

Keep it simple

Your priority is delivering great care, so obtaining consent to use scribe software should take just a few seconds. Rehearse a simple statement that is direct and concise. 

You might say something like this:

“Before we start, I would like to use an AI scribe to document our conversation and capture the important details for your medical record. Are you alright with that?”

Speak to benefits

Public surveys show that many patients are still uncomfortable with the idea of AI playing a role in their treatment. Even though your AI medical scribe is simply a documentation tool, mentioning how this technology improves their care is helpful.

Here are two phrases you might use to communicate the benefits of using an AI scribe:

  • “The AI scribe takes notes for me so I can focus on our conversation instead of the computer.”
  • “Using this tool helps ensure I capture all the important details from our conversation and save these in your medical record.”

Respect patient preferences

If patients have concerns about your use of an AI scribe for documentation, respect their preference. You’re not there to have an ethical debate or convince them of the benefits. 

Most physicians find that patients are happy to use an AI medical scribe for documentation. In cases where patients aren’t comfortable with this technology, consider using your smartphone to dictate notes quickly after the visit.

Comments are closed.