The digital era is gradually taking over our institutional memory in healthcare. Every year, the next generation of physicians enters the workforce with no lived experience of a paper-based, analog medical system. I’ve been a practicing physician long enough to remember paper records, and I’ve seen the transformation from paper records to “electronic paper” to digital innovations we’d never have imagined in the 20th century. The explosion and evolution of technology to capture and inform the essence of both the patient condition and the care we provide has all transpired in my professional lifetime. As a witness to that revolution, I have learned a few things about healthcare – especially about what the humans using technology still must do, no matter what we’ve been able to make technology do for us.
Taking a stroll down memory lane, I recall the era of paper charts well. They were really just folders with metal brads on top to secure all the papers held inside. Everyone had little reinforcement stickers in the shape of a donut to place over the hole punches when the fragile paper ripped. It was commonplace to maintain a patient summary on the left side of the chart, with encounter notes in chronological order on the right. For primary care, that left side was the source of truth, meticulously curated to ensure accuracy of the problem list, medication list, health maintenance services, and other important information needed at a glance. The patient summary was essential to create instant patient context, and it was the cornerstone of comprehensive, longitudinal care. We either wrote this summary in pencil for easy updating, or we used “white-out” to make corrections to entries written in ink. This may sound foreign to the youngest of my physician colleagues, but my fellow veterans will recall this bygone era with nostalgia — we could page through encounter notes to forage for details when needed, but the left-hand summary was vital to safe, high-quality patient care. It was sacred.
We all know how this story evolved. As electronic health records (EHRs) began to permeate the industry with the promise of efficiency and more reliable patient information, physicians became tethered to their computers, toiling away for many hours after the last patient of the day had left. Despite their many benefits, EHRs became the antithesis of efficiency, costing physicians both revenue and access, while the price of EHRs drove up overhead expenses, which practices could scarcely afford. Although they were imperfect, we longed for the simpler days of our paper records.
There’s no denying that the introduction of electronic health records revolutionized healthcare delivery. EHRs, for both better and worse, have become central to the physician’s workflow and the care delivery experience. The patient summary, once full of eraser marks or correction fluid, is now curated electronically and remains as vital to the sensemaking of a patient’s longitudinal health information as it ever was. While many other technology solutions have been propagated across the industry to serve a wide variety of purposes, the centrality of the EHR cannot be displaced.
Two decades later, the industry is entering a technological revolution of a different kind: the introduction of artificial intelligence (AI), machine learning, and large language models. I am excited about the possibilities created by these technologies. AI has the potential not just to liberate me from my mouse and keyboard, but also to synthesize large amounts of information, surface buried insights in seconds, and see into my blind spots. It can generate high-quality, well-informed predictions, delegations, and communications. It can coordinate the hundreds of wishes I cast into the universe for my patients. The industry is erupting with startups offering novel AI products aimed at long-standing problems overdue for solutions. This is a monumental moment in healthcare, and the rush to join the fervor is palpable.
Physicians cannot escape the EHR. The EHR, which has colloquially been referred to as “the physician’s living room,” is where we carefully store, curate, and comprehend the best we know about our patients. It is where we do our most intense clinical thinking and problem solving. And it is where we know to go if ever there is a question, concern, or new revelation about a patient to formulate a complete picture.
With very few exceptions, all physicians use EHRs to get their daily work done, and now they are eyeing artificial intelligence with a mix of hope and skepticism as the industry launches into a flurry of development, making its debut with AI-powered ambient scribes. AI scribes transform patient encounters into an accurate, comprehensive, structured note, saving the physician hours every day.
But the concept of scribing is not new. The precursor to the AI scribe was the human scribe. Human scribes, just like AI scribes, free the physician from the computer, but they are much more expensive. Yet, we have not necessarily seen a mass abandonment of human scribes to adopt the more cost-effective AI scribes instead. Why not? The answer lies inside the EHR: human scribes are working inside the EHR just like physicians. They have access to the entire chronological history of the patient, the consultant’s notes, the lab and imaging results, and the full patient summary. Like an assistant, human scribes can nudge the physician about reminders, point out details the physician may have missed, and look up important information on the physician’s behalf without disrupting the patient’s experience. Human scribes can draft orders, craft letters, and effortlessly translate a lay conversation with a patient into professional language meant for clinical documentation. Human scribes have context, whereas stand-alone AI scribes have to guess.
Knowing that the EHR is my “living room” and holds the most valuable items of recorded information available to me as a physician — the patient’s longitudinal record — I have to wonder: How much more impactful could AI be if it were like a personal assistant in the living room with me, instead of a tradesman standing outside my house? What if AI had access to all that rich context in the longitudinal record? What if we could take the sacred patient summary, so carefully curated, combined with the mountains of data tucked away in various pockets of the patient’s record, and set AI up to function like a human scribe, only better?
We are at a pivotal moment in the evolution of health technology, and we have to decide what work we want AI to do. The trend of standalone technology solutions that either don’t integrate or loosely integrate with the EHR is not new, and the list of AI solutions following suit grows by the day. What we don’t need is 1,000 disparate solutions for the 1,000 jobs physicians have to do. We know that this approach fragments clinical workflows; duplicates data; and adds to the cost, complexity, and inefficiency of care. Stand-alone AI solutions feel like a tragic missed opportunity when we consider the magnificent power of AI to improve what physicians do for their patients. AI solutions baked into the EHR experience could radically transform the clinical effectiveness of physicians by leveraging the richness of the longitudinal patient record, while also creating efficiencies that give them back more time to care and create more revenue.
This is an opportunity (unlike the experience we’ve had with the introduction of EHRs) to replace the nostalgia for that bygone era of the simplicity of paper charts with joyous enthusiasm for a technological breakthrough that finally does something physicians actually want.
Let’s not waste it chasing solutions outside the house.
Let’s invite it into the living room.
Photo: invincible_bulldog, Getty Images
Dr. Sara Pastoor is a clinically active family physician and currently serves as the Head of Primary Care Advancement at Elation Health, where she advocates for primary care and its powerful role in healthcare. She also is the personal PCP to patients at People-Centered Health, a direct primary care practice in Texas. She is a Fellow of the American Academy of Family Physicians and spent the first 15 years of her career in the Army Medical Department, helping to lead the Military Health System transformation to a patient-centered system for health. Dr. Pastoor has also led patient-centered transformation, primary care expansion, and EHR workflow optimization in the academic and employer-sponsored primary care settings during her 26-year carer in health tech. On the weekends, she volunteers in a free primary care clinic, teaching students and serving an indigent population in her hometown.
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