Ambient Clinical Intelligence (ACI): Rising Above the Noise to Create a Business Case with Confidence

What Leaders and Clinicians Need to Know to Create a Business Case and Educate Their Team

Let’s be honest, the advent of the Electronic Health Record (EHR) did not make documentation easier for clinicians. Quite the contrary.  Clinicians report spending countless hours on documenting, sacrificing valuable time they could be spending with their patients and their families. Despite interim solutions over the years, such as dictation/transcription services, voice recognition/speech-to-text Natural Language Processing, and medical scribes, most organizations and clinicians have been grasping for technology to make documentation easier and more “real time” for over a decade. In the meantime, clinicians and patients have suffered... until a new generation of AI emerged. 2023 and 2024 have seen the advent of large language models (LLMs) that are trained on clinical notes.

This technology offers new abilities to “listen” to the clinician-patient visit conversation via ambient clinical listening and generate a physician note of high quality in real time. What we are experiencing is the convergence of front-end speech: scribing and dictation. All three historically disparate solutions are merging into one Ambient Scribing and Autonomous Dictation workflow. The overlay of this advanced ambient clinical intelligence (ACI) technology reduces the need for human Quality Assurance/editing, and dramatically decreases the time clinicians spend on documentation. ACI is improving the integrity of documentation, reducing the need for humans to QA, and is currently taking the industry to a whole new level of clinician and patient satisfaction.

Business Case Outline and Components

While purchasing a form of ACI is an investment, there is a clear return on that investment. You will win, the clinicians will win, and your organization will win. But does the leadership team understand? Ambient documentation technology is in high demand, becoming increasingly common and starting to show a promising future, but organizations need to be aware of the higher risks of missing crucial details and inconsistencies in clinical notes to ensure optimal reimbursement. This is the first of three blogs that will educate you on the evaluation process, help you create a business case to drive approval for future consideration of ACI technology, and prepare you to optimize adoption in your organization.

Writing a detailed business case is crucial to gain executive approval to move forward with evaluating technology and drive a streamlined process. The business case will not only outline recommendations, but it will also provide the details needed to foundationally educate the team and frame up the project. It should identify the why, what, how, and who of the purchase considerations.

Describe the problem or opportunity - include an account of your current state
Describe the ACI technology and why it is a solution consideration
Establish top vendors in the industry for evaluation
Establish evaluation criteria - a weighted matrix tool with key considerations for choosing
Identify the internal stakeholders/project team and recommended timing for evaluation
Provide comparison and official recommendations
This is your outline, but the 3-part blog series will instruct your next steps and inform your business process.

What is Ambient Clinical Intelligence (ACI) Technology?

Ambient Clinical Intelligence (ACI), or ambient listening, is a silent AI supported tool that listens in via a clinician phone or speaker, transforming a conversation between a patient and clinician into an organized and templated clinical note in seconds. The technology also maps the elements into the discreet data fields of the EHR. This alleviates an incredible amount of clinician administrative burden and improves the integrity of documentation. While the clinician needs to review the clinical note and edit, it can be done immediately, while the patient encounter is fresh. Clinicians are finding that they are getting their lives back with this advanced technology.  

The Advent of Ambient Clinical Intelligence (ACI) Technology?

Technically speaking, why now? The launch of large language models (LLMs), including OpenAI's GPT-4, Google's MedLM and Gemini Pro, Anthropic’s Claude v3, Meta's LLaMA 2 and Mistral’s 7B. These announcements sit alongside success by NYU, UCSF, and University of Florida health system researchers to create, deploy, and open source LLMs that are trained on clinical notes. LLM's improve automated speech recognition (ASR) and natural language processing (NLP) accuracy by ~30% over current best-of-breed models and offer new abilities to summarize the ambient conversation by speaker and automatically create a physician note. This advanced technology can discern between multiple speakers in the room and translate only the pertinent clinical details into an organized format. This is a breakthrough! 

Next to providing the highest quality care for the patient, there is nothing more important than complete and accurate documentation of the care. This translates to fewer medical errors, better continuity of care for the patient, better communication among the clinical teams, and accurate reimbursement. These days, most healthcare facilities must operate as an efficient business to remain viable. The reality is that all facilities and clinicians strive to have high patient satisfaction ratings and optimal reimbursement. It is hard to connect to a patient when a clinician focuses on the computer screen more than the “person.” We are all human and we want to feel heard and seen. The perception is we are not fully understood unless we are seen. The connection is critical. ACI is actively helping with this and so much more.  

What are the Key Benefits of Ambient Clinical Intelligence (ACI) Technology? 

There are multiple documentation approaches using ACI technology, all hinged on expansion of the clinician’s current state of documenting – ACI with physician editing; ACI with transcriptionist editing; ambient scribing. Each have their advantages, and these typically rest on clinician preferences. Regardless of the ACI approach to the real-time generation of the note and mapping to the EHR, the benefits are identical:

Patient Satisfaction – By enabling clinicians to focus on patient engagement, ACI enhances the patient experience, fostering a stronger relationship with the clinical team.
Clinician Satisfaction - ACI allows clinicians to dedicate more time to patient care, reducing administrative burdens and potentially increasing patient capacity. Real-time note generation facilitates immediate review and editing, contributing to overall satisfaction.
Quality of Care – Real-time documentation ensures comprehensive capture of clinical details, enhancing note accuracy and ultimately leading to better clinical outcomes and fewer errors. According to a Frost and Sullivan report, AI could reduce medical errors by 30-40% and lower treatment expenses by up to 50%.
Financial Outcomes – Optimized quality coding, reliant on complete and accurate documentation, forms the basis for reimbursement. With ACI facilitating real-time documentation, the coding process accelerates, leading to faster billing cycles and improved cash flow.
One crucial point is that the outcomes and benefits can only be realized if the clinicians say what they are thinking during the conversation with the patient. Since this is not a traditional dictation, but reliant of conversation during the visit, clinicians must speak their critical thoughts aloud for the AI to “hear” and capture in the note. While Free Dialogue promotes a more natural interaction, it presents risky omissions and inconsistent, non-standardized/EHR templated data.

What are the use cases of Ambient Clinical Intelligence (ACI)? 

According to many surveys in the industry, clinicians and organizations are highly interested in ACI technology. However, the technology is best suited for certain specialties that are more routine, repetitive, and on the move. The LLM technology requires large data sets to train the models, therefore the specialties that have shorter visits at a high volume will have better predictability and automation outcomes. For instance, an allergy practice who incentivizes their clinicians to see fifty or more patients per day is a perfect fit for ACI. Other examples of service types that fall into this category of “fast and finite” include Primary Care, ED, Physical Therapy, Telemedicine. Examples of specialty clinics/practices include Cardiology, Orthopedics, Rheumatology, and Neurology. 

Key Selection Criteria Checklist (Functionality) and High Level Evaluation Notes

When evaluating vendors, it is critical to create a checklist of key selection criteria. This ensures parity among the selection team and will streamline your process. The checklist below will give you foundational criteria to consider using in a scoring rubric:

Timeliness of note generation - The note should be generated in minutes for editing and finalizing.
Error rate at start, 3 months, and 6 months (projected) - Overall, the accuracy of the ACI should improve by approximately 30% compared to speech recognition or natural language processing. This is typically achieved incrementally, over time.
Structure of note generated - Ensure the structure can be customized ie. SOAP, HPI, Assessment, treatment plan, discharge instructions, etc.…
Predictive analysis - Does the product have the ability to formulate diagnosis predictions based on a compilation of clinical data, lab tests, etc.?
System workflow and ease of use - Vendor should assess the current state and identify the best workflow/approach for the clinicians to ensure the least disruption to UX and ease of editing. Integration with EHR - Can the information from the clinical note be mapped to discreet fields in the EHR? How? Are they deeply integrated with the EHR and making it part of the actual EHR?
Security, privacy, HIPAA compliance - As with all systems that collect and analyze patient information, there should be strict policies around data encryption, access controls and auditing. Preventing PHI breaches is a critical step of evaluation. This is one of the most important aspects for ensuring positive patient perception and trust.
Time savings average - Average time savings equates to approximately 10 minutes per note.
*Evaluation notes will be addressed further in Blog 2 and 3

Key Selection Criteria Checklist (Support and Pricing) and High Level Evaluation Notes

Ease of Adoption + Training/Support - Look for a user-friendly option that is easy to adopt with very little training needed. But you want the vendor to hold the provide ongoing support during and after implementation. This should be outlined in a transparent plan and customized to your organization.
Vendor relationship - Is the vendor responsive, accommodating, and listening to your needs? Is it a true partnership?
Cost - Do not seek the cheapest option - seek fair pricing.
Pilot offered - Length and paid or free? Some vendors offer a limited time pilot. This will allow hands-on evaluation of the technology and gauge clinician satisfaction before you purchase.
Demonstrations of the technology speak for themselves. It's important for the vendor to include an impromptu conversational encounter in their demo. This confirms that the output is genuinely a product of ACI and not simply created in the background for show. Unlike previous voice recognition tech, ACI doesn't need voice customization or training. If it's genuine ACI, it should be easily demonstrated.

Industry Lessons Learned & Potential Challenges

Considering the myriad benefits of ambient clinical technology, adoption undeniably seems inevitable. Similar to the evolution of EHR systems since the 1980s, the integration of dictation, scribing, and front-end speech services into ACI technology has been ongoing for over three years. This provides valuable lessons for implementation. Key considerations include: 

Say What You Think – Clinicians must adapt to articulating their thoughts conversationally during patient visits to ensure accurate translation into clinical notes, reducing the need for extensive editing.  

Clinician’s Current Documentation Approach – Current state is critical when considering which clinicians to include in ACI. It is not best suited for all clinicians, especially those that are sensitive to editing their own work. Clinicians will have a higher satisfaction rate if they are currently editing their notes and are counting on a more timely return of the note draft. It is critical to consider the impact on the HIM team. 

Hardware Optionality – Speed and time are of the essence. It is critical to ensure the clinicians have the option to use mobile devices and laptops for the ambient listening and the editing session. It is also crucial that the product has a streamlined, user-friendly workflow. These will drive their willingness to adopt the technology and their overall satisfaction.  

Affordability – As with all technology, the cost of the ACI products particularly can be a challenge. Many who see the value of ambient outcomes  generally cannot afford the investment. Just remember, there are many vendors who are popping up saying they can offer a lower cost option. Be sure to confirm they are healthcare terminology tuned models and have proven outcomes before you choose to partner.  

In addition, our next blog will cover key considerations for the selection process, implementation, and adoption. Don’t miss it!