A patient-centered digital scribe for automatic medical documentation

We developed a digital scribe for automatic medical documentation by utilizing elements of patient-centered communication. Excessive time spent on medical documentation may contribute to physician burnout. Patient-centered communication may improve patient satisfaction, reduce malpractice rates, and decrease diagnostic testing expenses. We demonstrate that patient-centered communication may allow providers to simultaneously talk to patients and efficiently document relevant information.

We utilized two elements of patient-centered communication to document patient history. One element was summarizing, which involved providers recapping information to confirm an accurate understanding of the patient. Another element was signposting, which involved providers using transition questions and statements to guide the conversation. We also utilized text classification to allow providers to simultaneously perform and document the physical exam. We conducted a proof-of-concept study by simulating patient encounters with two medical students.

For history sections, the digital scribe was about 2.7 times faster than both typing and dictation. For physical exam sections, the digital scribe was about 2.17 times faster than typing and about 3.12 times faster than dictation. Results also suggested that providers required minimal training to use the digital scribe, and that they improved at using the system to document history sections.

Compared to typing and dictation, a patient-centered digital scribe may facilitate effective patient communication. It may also be more reliable compared to previous approaches that solely use machine learning. We conclude that a patient-centered digital scribe may be an effective tool for automatic medical documentation.