Best Coding & Documentation Products

AI-assisted virtual scribes refer to software that specializes in charting physician-patient encounters in real time, such as during medical examinations. The software is able to process natural language and has been trained specifically to document clinical encounters. These types of solutions have become possible with advances in artificial intelligence and machine learning and provide an alternative to remote scribes or in-person scribes, who accompany a physician in the exam room. They have the potential to be significantly more cost effective than solutions requiring human support.

Clinicians are spending a disproportionate amount of time working within electronic health records or performing clerical work. Incomplete documentation may lead to inaccurate code assignments, resulting in underpayments for episodes of care. Health systems are therefore met with the challenge of keeping clinicians from becoming disconnected and fatigued due to administrative tasks while also addressing the shortage of coding resources. More efficient coding procedures can optimize revenue cycle, address risk adjustment needs, improve quality outcomes, accelerate workflows, and increase clinician satisfaction while minimizing burnout.

Dictation software allows physicians to use voice (and vocal commands) rather than to type notes by hand. Recent advances with commands empower physicians to further navigate the EHR in a hands-free way. While speech recognition technology has improved, the dictation itself often occurs in between patients or after hours. This means that while screen time can be reduced, the physician is still completing the documentation.