I'm a healthcare CIO of 12 years, and I've evaluated 4 and deployed 2 of these tools, one of which is currently deployed at my currently healthcare employer. I am very measured on AI but the results I've seen from these virtual scribes is HUGE. In every case we have IMMEDIATELY seen improvements in patient NPS scores, provider satisfaction, and note quality. Notes are more standardized as well as more verbose and detailed, which makes it easier for future providers to understand the case. These better notes reduce our claim rejection rate.
And what converted me was direct patient response. Across the board patient feedback is extremely positive, with the most common comment being along the lines of "I really felt like the doctor connected with me better and they were more present in the visit."
These AI scribes really DO improve patient care, I've seen it with my own eyes.
=> the error rate was 7.4% in the version generated by speech recognition software, 0.4% after transcriptionist review, and 0.3% in the final version signed by physicians. Among the errors at each stage, 15.8%, 26.9%, and 25.9% involved clinical information, and 5.7%, 8.9%, and 6.4% were clinically significant, respectively.
=> Omissions dominated error counts (83.8%, p<<0.001), with CAISs varying widely in error frequency and severity, and a median of 1–6 omissions per consultation (depending on CAIS). Although less frequent, hallucinations and factual inaccuracies were more often clinically serious. No tested CAIS produced error-free summaries.
On the gripping hand, people who work in the management end of the US healthcare industry can't be trusted with healthcare or information security to begin with.
My dad likes to joke around and his doctor uses some kind of transcription service. Time for fun!
His doctor asked him about using drugs and he made a joke that was something like "I only use coke" - meaning coca-cola. Of course his doctor knew he was kidding about drinking too much soda because he eats/drinks too much sugar. So they had a little laugh and moved on.
BUT now it's in his medical transcripts. My mom said it "transcribed" it as something like "the patient responded he has used cocaine recently".
I guess his doctor doesn't go in and actually fix things or even read over what the transcription says...
Also both of my parents have accents and have reported really weird transcriptions that don't match what they actually said.
So now my mom has told my dad he can't make jokes with the doctor anymore because even if the doctor knows he's joking it's going to get noted down as a "fact".
I've ended up with an erroneous medicine allergy on my record because I mentioned a well-known side effect to that medicine during an office visit a couple years ago. Some "moving part" in the system (be it a human entering the doctor's notes, a transcriptionist, etc) interpreted what I said as an allergic reaction and now I get asked about that "allergy".
I've asked to have it fixed but other facilities have gotten "copies of my records" and I've had it crop up in visits to other providers.
Thankfully it's not a medicine that's likely to ever be administered to me (or not administered when I'm incapacitated and can't point out the error) so I'm not worried, practically. On principle, though, it really frustrates me. It seems like it will never be fixed.
This feels like a compelling reason to joke around more.
If inaccuracies make it to your patient record, it's defamatory. Your doctor must sign off on the transcript and if they're letting through poor results, make it their problem to fix. That'll either force the tech to get better or to fall back on better note taking practices.
Might be immature but personally once I knew this was possible I'd go for the high score. Try to get every substance I can think of listed plus a supposed admission of murder and whatever other ridiculous stuff I can come up with.
"Well you know me doc, I keep my drugs in the deep freezer with the bodies waiting for disposal so I'm quite confident in their shelf life." I wonder what an AI scribe would make of such a remark.
Imagine if his health insurance premiums got raised because of it, if he loses a job opportunity due to background checks or if he gets arrested because of it. Even going through customs or getting a visa can be tricky with a history of cocaine on your record.
my father has cardiac issues, serious ones. When a doctor asks what he wants to do he routinely says "Sail around the world, solo!" because that's about the stupidest most risky thing a person with a bad heart could consider.
So now every single doctor reads the transcript and starts with saying "I think it'd be really poorly advised for you to keep considering your worldwide solo voyage."
AI summarization doesn't carry the tone well. Most any but the most serious humans would catch the way he's saying it as a joke.
Errors can be a significant problem in manual charting as well.
I know a medical professional who does a similar evaluation process to what is outlined in your second link to human written charts. They then use that feedback to guide the department on how to improve their charting.
So, don't presume that those error rates cited in those studies should be compared to a baseline rate of zero. If you review human-written charts, you will often also not have an error rate of zero.
It’s been a year or so since I last read The Mote In Gods Eye/The Gripping Hand but I randomly was thinking of this morning. Very funny that I would see a reference to it the same day.
Be careful with initial impressions of metrics. We as humans have a heavy tenancy to anchor to our first judgments or impression. We see a win and assume the win is long term, with no downsides, and dependent on the new information/change.
So combine that with the Hawthorne effect and new business or health initiatives that can look great simply because participants notice change and notice the increased attention. However many human patterns have a tendency to regress to the mean.
Personally I have seen this a lot with developer tools and DevOps. A new SEV/incident/disaster happens and everyone rushes to create or onboard to a tool that would help. Around the office everyone raves about it and is sure that it would fix all issues. And the number of commits goes up, or the number of SEV's in an area decreases for a while. People were paying attention, after a while the tool starts to slow down or not be as used. It's got rough edges that weren't seen or scenarios that were supposed to be supported never get fully integrated. Eventually the patterns regress, but with more tools and more complexity.
I got an erroneous Type II diabetes diagnosis dropped into the note by the AI scribe at my last appointment because my PCP discussed the A1C test he was ordering. Would not recommend. That isn't to say that manually typed notes or speech to text dictated notes are perfect (dot phrases have ended up "documenting" plenty of conversations that never happened), but a false diagnosis of a chronic disease seems like a really bad failure.
> I still don't want a fucking audio recorder in my doctor's office ...
If I got a copy of the raw recording I might consider it. Maybe. Having that audio recording would be valuable to me.
It's very irksome medical providers I visit have signs posted prohibiting audio and video recording by patients. My medical appointments aren't exceedingly complex, but a reference audio recording would be handy.
I suppose I could exercise civil disobedience and just record anyway since it's not illegal in my state. Still, it irks me.
This feels wild to me. I think I am pretty well privacy obsessed, but I don't see it here (fwiw, my wonderful doctor has been using these services for years; originally with overseas human labor, now with AI). First off it presupposes some level of privacy with one's GP that I would only want from a therapist. I don't want health information going beyond my doctor? What about him talking to specialists or getting another opinion in the break room?
Ship's sailed on that level of privacy anyway the second you bill an insurance carrier in the US. I am willing to take this particular risk if something I said two years ago pops up to help explain what I am currently experiencing. I understand not everyone is me and I am lucky to be in relatively good health and not have anything going on that might put employment, etc at risk so I can understand where some people may want to refuse. But the knee-jerk "FUCK NO BECAUSE PRIVACY" is almost as bad as writing a post based on a side plot in The Pitt when said side plot was 110% heightening the stress between Dr. Robby and Dr. Al Hashimi, not a goddamn double-blind study of the effectiveness of AI transcripto-bots.
And if you're going to take lessons from The Pitt about medical record transcription, why isn't it Dr. Santos repeatedly falling asleep while transcribing records?
For now. It always begins as voluntary. But then doctors will start to treat people who opt out the way TSA treats me when I opt out: a hostile adversary.
I already get glares and sighs when I dare to actually read every word of a multipage form I am expected to sign without reading. Was told once I would lose my appointment if I took longer than a few minutes to read more than 10 pages because I could not be checked in until I signed. Other patients are waiting, your exercise of your human rights is inefficient.
Then soon I'll have to pay a higher copay to opt out. Then I won't be able to opt out at all.
All in the name of optimizing patient NPS scores and patient throughput.
I've never had this problem. IME every doctors office recommends showing up 15-20 minutes early to a new-patient appointment for the explicit reason of filling out paperwork.
Right, doctors and CIOs get to use AI transcripts but you, a lowly patient, will write your name, address, and insurance policy number fifteen times with an exhausted Bic pen.
>For now. It always begins as voluntary. But then doctors will start to treat people who opt out the way TSA treats me when I opt out: a hostile adversary.
> Was told once I would lose my appointment if I took longer than a few minutes to read more than 10 pages.
I'd be finding a new doctor at that point. Ridiculous. I love it how doctors can be 30 minutes late for their appointments because they're running late and all their appointment delays are cascading, but if the patient reads a document for 5 minutes, they're the problem!
You can do that by recording and transcribing (many methods) or your doctor has to write on the fly, or worse, has their head in their computer while you talk in their general direction.
Letting doctors talk and examine and not write is a wholly better experience.
Offsite third parties are the problem here. If this was done automatically without data leaving the room, is there a problem? Do you have the same objections to how your digital notes are stored?
Maybe it's a regional thing, but in my last 3 appointments, 2 had an assistant doing the note-taking (as prompted by the treating physician or PA). The third was a virtual appointment, so no idea what notes were taken, if any.
> I still don't want a fucking audio recorder in my doctor's office
Why? Doctors have the strictest privacy regulations I know of. It's the one place where I'd be least uncomfortable with a recording, because there's nothing they can do with it other than use it to provide healthcare to me.
> or a fucking AI that sits in between me and my doctor.
The expected arrangement is that the AI would be alongside you and your doctor, so that your doctor can spend time interacting with you instead of playing transcriptionist and dictating your statement into your chart.
I’ve been in tech and medicine too. Consider that any “HUGE” effect in this context is likely exaggerated, especially for something as prosaic as a note-taking assistant.
As a patient sitting with a doctor, I don’t care how standardized the notes are. I don’t care about anyone’s NPS score. I do want the doctor to connect with me, but I also remember not too long ago when doctors did this anyway, without any assistance from robots.
I also remember not too long ago when doctors did this anyway, without any assistance from robots.
Or with assistance from other humans.
The last time I had surgery, every time I met with the surgeon (about six times), he had an intern following him around with a Thinkpad, typing in everything said.
The intern has the ability to understand context, idiomatic expressions, emotion, and a dozen other important and useful things that an AI transcription will never capture.
That’s probably not an intern. Doctors with enough pull can get dedicated scribes like this, but they aren’t cheap, which is why most doctors don’t get them.
Were those surveys performed before or after the patient received the bill?
Getting billed for a "dietary consult" because your doctor may have asked you what you had for lunch due to the coding intensity of these scribes is asinine.
Not to be antagonistic, but a healthcare CIO in which country? This is very relevant because outside of the US, I think it is probably fair that most people who are most active on HN are from countries with public health care, and stronger consumer protection and privacy laws.
The healthcare outcomes are absolutely critical in evaluating the use and value of these tools, but there are second and third order effects from using the tools that need to be contextualized with the specific motivations of executives endorsing the tools.
> improvements in patient NPS scores, provider satisfaction, and note quality
How are note quality improvements measured? Vibe-notes might be more verbose and better sounding (which would explain the NPS and satisfaction metrics), but still not actually match the doctor's actual words or intent. Are the AI-generated notes actually compared with ground truth to prove they are accurate?
Once you've had your medical records used against you by a third party, you start being much more careful about what you share with your doctors about yourself.
There is no trust in a Dr's office. What they record gets handed to companies who have interests adversarial to yours. Basically like talking to the police. If you, as a patient, think an automated recording is helping you long term, you are naive.
Yep I would agree as a patient. My current doctor types so slow that 6 out of the 10 short minutes in an appointment just disappear while he types. Even with other docs who can touch type, it will free them up to focus completely on the appointment and reduce the hours they spend charting afterwards.
In an article critiquing over-use of AI assistants, the author confesses at the end this article itself was authored partly by Claude that introduced errors in the citations, lol.
Nonetheless, I come away from this article with the sense the ambient devices automating documentation of an encounter are still a net win, with caveats about the need for the doctor to polish the note ti reflect his or her own narrative voice.
"I am not saying ambient scribes are bad technology."
is this a counterpoint? he just seems to be wary of the risk, without a firm position and decided to personally stop using it. people often overestimate their own skills and think their own charting is better than that of others, that doesn't mean the tech doesn't work.
1) in the event you find yourself partially or totally disabled but the records don’t really make a good case for it and your provider has a dismissive attitude about filling out additional documentation to substantiate what they failed to in your records.
You’re not necessarily going to get approved for FMLA, STD, LTD, SS etc based on a diagnosis or test results alone. They will nitpick over say, heart failure, as if that’s magically and spontaneously going to go away. If you’re telling your provider that you’re limited by things like oh I don’t know, “I’m only awake for 2-4 hours before I need to sleep again” or “some days I just can’t do it and sleep 20 hours” but it’s not in your chart… expect denials and clarifications and a huge burden on you to prove why it’s limiting.
2) continuity of care, so you don’t end up explaining everything from the top to a specialist or having them run all these tests and procedures from square one — when there’s months long backlogs , and we already did all this and you need treatment - but - there wasn’t much to work with in your referring chart.
You might not appreciate the “intrusion” if you’re healthy and just worried about your privacy.
If/When things go south and you find yourself fighting these entities for a year or two or three while they nitpick and delay and deny and drag their feet , you’ll be glad an “AI” kept up meticulous records because this is phenomenally stressful and an endless burden on you when they don’t.
So, their AI slop can vomit out all this extra info on why insurance companies should pay them or why your condition is in fact disabling, and now their AI slop can comb through it looking for all that. Because they will try to avoid paying or approving any kind of leave or benefits if it’s not there
And god forbid you hand them a form where they’re being asked to explain themselves. 50/50 on them being eager to help out or rolling their eyes and saying something really nasty about the imposition. And then even when they do that, they almost never file a copy in your chart so your chart STILL doesn’t substantiate your claims. I’m all for an “ai” doing the progress notes in a case where the facility or provider can’t be fucked to do so.
Happily that’s not true of my current provider, who just, does that anyway (?) But I’ve been around enough to know they’re an exception. Even when providers are on your side and mean well, and want to bend over backwards to help you in any way they can — and I want to just acknowledge that’s the situation I’m in today — honestly , sometimes they just forget some of the details when they do their notes.
That’s why some places make the provider do it in real time while they’re talking to you, so they didn’t forget something relevant thirty minutes later. The other side of the coin here may be that some providers find that distracting or off putting to be typing away like a stenographer while they’re examining you…
I think it would be fair to say this can all be tedious and a burden for both patients and providers. There’s just a world of difference between a provider who wants to do this to provide excellency in care, and a provider who wants to do this because they resent it and think it’s beneath them.
How do you control for quality variation between patients? In my experience, AI note taking tools display a clear bias against participants who are {quieter, ESL, women, ...}. How can you evaluate whether these biases show up in a medical setting?
Good, I'm glad. Now find a way to do it in-house. Shipping our conversation to some random-ass fly-by-night SaaS who pinky-swear-promises they're HIPAA-compliant is a non-starter for a medical professional I'd actually want to give money to.
As a husband of wife who is GP, I would add a general long term issue - cognitive overload. GPs have to be almost-expert in everything, my wife is doing everything from preliminary cancer diagnosis and treatment, heart attack diagnosis to psychiatric care and many other places in between which should be normally covered by specialists.
But there are simply not enough of them here for many tasks here (Switzerland). Any mistake can be potentially fatal to the patient, easily, trivially.
The amount of self-imposed stress and responsibility compared to puny insignificant software dev roles like mine is staggering. And its every single day, no easy day, ever.
On top of that, 3-4 hours daily just doing paperwork for insurances, legal, judges etc. that has to be flawless. LLms can help massively here, but it would be great if they are opt-in for patient (and thus he can get better focus of doctor / longer time spent / lower meeting cost), and if they could be local-only. Absolutely nobody from anywhere in Europe wants to send any data to US nor any of their closer servers, that game is closed for good.
You had it 20 years ago: doctors spoke into recorders, transcriptionists turned that into notes, the docs reviewed them.
The first study I cited replaces the "spoke into recorders" stage with non-AI voice recognition.
The second study replaces the "spoke into recorders" stage with LLM voice recognition, and... crucially... also replaces the educated transcriptionist step with nothing.
I imagine that the real problem is that the voice recognition can be classic or LLM and it just doesn't matter as much as having two humans in the loop instead of one. But that's not a story which gets you to replace cheap voicerec with expensive AI.
If I allow it, is the data from my meeting sent offsite at any stage, for example to an LLM service (e.g., Anthropic, OpenAI, etc.)? Or do the LLM vendors (or any others) have access to the internal data at any stage?
I think this is just humans not understanding things and irrationally being afraid of one thing more than another thing. You're afraid of someone listening to you; you're not afraid of someone copying the documents that detail every single aspect of your health (EHR records).
Healthcare records are probably the most strongly protected personal information in the world. Remember that most of the data about you is not protected by law. Credit reports, ISP records (including your SS#), your entire email archive, Google Drive, etc could get leaked, and for the most part there's no legal consequence. But if a record of you having the flu in 3rd grade gets leaked by a 3rd party connected to health record keeping, there are real consequences (not only for the leak, but even for not reporting it).
If anything, I want everything I say to be recorded and kept on file for later reference. The danger of speech-to-text engine transcribing incorrectly is real, but that doesn't mean I don't want the notes there. I just want the audio included with the text. Both will be useful to refer to later on, especially as STT models improve their accuracy (we've seen amazing leaps in accuracy in just 1 year).
However, we do need to ensure that these records are protected from government over-reach. Currently the government can request your health records, without notifying you, for a slew of reasons. This enables the government to go on a fishing expedition, doing the equivalent of an unreasonable search of private information, and you will have no notification and no way to respond. We must create laws that provide stronger privacy rights for sensitive health information to resist government overreach. Another legal hole is 3rd party apps that collect sensitive health information, but aren't provided by your doctor. Your step-tracking, heart-monitoring app is not protected by HIPAA. Same for employer health records.
I understand the concerns and I am not sure I would allow myself to be recorded until I knew more.
However, I do think we are in a situation where everybody knows that healthcare costs need to come down that doctors and medical professionals are spread too thin, forced to see evermore patients in the same number of hours, and yet for every attempt to improve efficiency there is a “no, not that way“ response.
If I paid all my doctors $1200/hr and doubled how much time they spend with or on me, that'd still pale in comparison to healthcare expenditures attributed to me between actual insurance payments and actual money leaving my bank account. Doctors being spread too thin is very much a separate issue.
I definitely agree that medical professionals are spread too thin and automation seems like it would be a boon but, as the article points out, the introduction of automation likely won't translate to more doctor-patient time it'll translate to doctors seeing more patients.
The solution not only introduces a problem (decreased privacy) but could reinforce the existing problem it's trying to solve.
> it'll translate to doctors seeing more patients.
This is also a good thing. Even in supposedly developed parts of the world like San Francisco it can be difficult to find a PCP that is taking new patients.
Where healthcare is concerned, America is not what anyone considers "first world". Your healthcare system is more backward than most third world nations. I would rather leave the US than receive medical treatment there. I have never even considered trusting the US healthcare system. When I lived there I would rather fly home and get treated (in a third world country) than lose all my savings getting inadequate care in the US. I know people who have been through large and expensive treatment plans in the global south, who paid less for the complete treatment than Americans pay for the ambulance getting you to the hospital.
Your healthcare system is more backward than most third world nations. I would rather leave the US than receive medical treatment there.
And yet the wealthiest people in the world, who can have the best healthcare anywhere they want on the planet, even with private doctors, routinely choose to be treated in Rochester, Minnesota; Boston, Massachusetts; Houston, Texas; Baltimore, Maryland; and Los Angeles, California.
The U.S. is by no means perfect, but there's a reason that there are entire medical facilities in the U.S. that cater exclusively to people from other countries. Just listen to local radio in Palm Springs and you'll hear commercials along the lines of "Tired of waiting, or simply can't get the medical care you need in Canada? Come to our hospital!"
Meanwhile, if I wanted to have my recent surgery in Canada, I'd have to wait almost a year for a slot to open up. Here I waited all of two weeks. And the newspaper headlines in the UK are full of horror stories of patients dying in hospital hallways while doctors are on strike because everything is so great.
> I do think we are in a situation where everybody knows that healthcare costs need to come down that doctors and medical professionals are spread too thin
The problem is over optimization AND lack of people. As soon as there's an excuse for less staff because we have "digital record keeping" we're going to have less money and even less staff.
Having in person or remote notetakers is a great entry level job to do before you become a doctor. It could be boring but at least the terms are familiar and you get to know the person you're working with.
It's not like healthcare is an impossible problem to solve that needs more tech, we just refuse to spend money on people and (inexplicably) cannot help but dump tons of money into tech.
> The problem is over optimization not lack of people or resources. As soon as there's an excuse for less staff because we have "digital record keeping" we're going to have less money and even less staff.
At least in my area, it seems like lack of people is a problem. Sometimes it's lack of people because the pay is too low, but more of it it's lack of people because the pool of qualified people is too small. And increasing pay increases healthcare costs, and healthcare costs are already very high. If digital tools allow the available staff to see more patients while delivering the same level of care (and without burning out the providers), then that means more capacity and less times people want to see a doctor, but can't. Similar arguments for same number of patients ans greater level of care. If it's more patients, but worse level of care, then it becomes tricky.
The lack of people is too low because the organization tasked with accrediting new doctors has a financial incentive to its current members to keep the pool of doctors low.
Yes, and also almost all of these issues could be ascribed to all digital medical record-keeping. The fact that AI transcribed it matters relatively little.
One massive way to reduce healthcare costs is to remove caps from becoming a doctor; as long as you pass the tests and meet the requirements, why are we turning doctors away? So that existing doctors can be paid well above the market rate. There's a reason there's so many doctors in politics - it's very important for them to protect this business model.
Profit margins are capped by percentage. That creates the perverse intensive for insurance companies to pursue ever increasing costs in order to increase profits.
How do you know it's not the other way around? Give consent to incorporate another technology that will keep wages the same but allow them to treat more patients and extract more profit for the shareholders?
2. The point of insurance is they're supposed to pay for shit
3. You figure out how to get them to pay for shit, sign an agreement that removes me of any patient responsibility of the balance bill, and assure me in writing that I will owe $0 no matter what
> for every attempt to improve efficiency there is a “no, not that way“ response
They've tried everything except "train and hire more doctors" and they're just all out of ideas aside from "erode patients rights and lower overall quality of care"
The economics of medical school cost, time, and capped residency spots (some would argue this is price-fixing with artificial scarcity) make it hard to just “make more doctors”. Combine this with a highly litigious society that always demands a full doctor (when for 90% of things an NP or PA would do) plus inverted population pyramid all exacerbate the problem.
We need more doctors now and it takes 12 years to make a doctor and by then the boomer cohorts aging and medical needs will peak.
Finally, even if we could do that, the top of the funnel candidate is substantially weaker with lower test scores and higher need for remedial classes. And for the good candidates, the ROI of medical school is not as good as it once was.
Exactly. It means that if you've ever tried to get an appt and been told there's a 4 month waiting list, AI could help get you in sooner. That is a real win.
There might be some real concern about the cognitive and patient-interaction impacts of speech recognition being used... but on the other hand, it's more likely that details are missed when information is captured manually.
And the privacy/informed consent concerns here are silly, they apply to any of your charted data... and if you're going to any office that doesn't use the latest technology, your patient information is probably being sent between offices over fax anyway.
This is seriously a good example of a domain that should enforce on-premises AI. Doctors absolutely can afford to buy an NVIDIA workstation. Transcribing text is not exactly super demanding, comparatively speaking. When did we even stop considering non-cloud services? If AI boomed 10 years ago, we wouldn't even be discussing this.
I know some European "automatic scribe" projects of the government sector. Their IT buys a physical GPU server hosted locally. Pretty sure it wouldn't be accepted otherwise (or maybe I'm just naive, but it sure is a topic they care about). The software stack is mostly open source, I think. It sure as hell doesn't talk to a big American cloud provider. (Well, the transcription service doesn't. Who knows what they do with the automated transcript. Probably the same thing they did with the manual transcript.)
I have been loving my new doctors recording and making everything available in the patient portal. No more trying to remember what they said. That’s huge, especially when dealing with elderly patients and being able to have their caregivers have access to it.
my boss fell in love with a software that invites itself to team calls, then retranscripts and summarizes... so the whole office has that automatically in ; once in a while my colleagues and i look into that report, it's sometimes hilariously wrong, most of the times just useless
> But, especially given the underfunded nature of the US health system, that is extremely unlikely to mean more time with each patient. Instead, it will mean more patients.
So that means if I try to make an appt, I'll have an easier time getting one? Sounds good, I guess.
[Doctor Stan dinghere, as a patient i have no trust or confidence regarding the security and integrity of my personal information in regards to AI scribing.
for this reason i will scribe for you, as that is the most accurate account of what i intend to communicate with you.
i will refrain from verbal communication and will provide on the spot written communication with respect to health care interaction. ]
I live in a country with free public healthcare. In a recent doctor's visit, the doctor was interviewing me while a nurse was typing into the computer. Presumably so that the doctor would have more time to attend patients and so that she wouldn't get distracted.
It's fascinating how this translates to the idea that in the USA, this should mean "more time with patients", but in reality also means "more patients", but is somehow bad because the is a monetary drive.
Doctors have always been into "more patients", though. To some extent, if you're a doctor, the upper bound on your pay is how much you charge * how many patients you see. This is why you occasionally get seen well after your appointment time; people are double booked because some % reliability doesn't show up, but sometimes everyone DOES show up to their appointment and now it's your problem.
So if AI scribes mean "less double booking" then that's kind of a win/win. Less patient time is wasted. Doctors can make more money by seeing more people on a given day. Seems fair.
I'm more concerned about a record being made in general, than how it is made. If were to be affected by a tragedy and visit a psychologist or psychiatrist to receive support, it would likely require a diagnosis of depression to get insurance coverage, and having that on my record could make it more difficult and costly to legally fly an airplane or own a gun, and who knows what else.
Get help if you need it. Having periods of depression on your medical record doesn’t make your life more difficult, unless maybe you’re trying to be a spy or an astronaut or something.
> "Here is a real concern about implementation" → "Therefore you should refuse entirely"
This skips the middle step of "therefore we should implement it well."
I'm not convinced that we should be allowing doctors to record patient visits at this stage yet, but I'm really not convinced by these points, which largely don't hold up under closer examination.
A few that stuck out:
"Privacy" - Labs are routinely sent to third-party companies, and we don't do informed consent for that. The third-party argument isn't unique to recording.
"False promise of efficiency" - This doesn't really have anything to do with patients at all. It's a criticism of medical office management, not of physician-patient interactions. Telling patients to refuse a tool because management might exploit the productivity gains is asking patients to fight a labor battle on the provider's behalf.
"Consent can't be revoked mid-visit" - Consent typically can't be revoked in the middle of an appendectomy, or halfway through administering a vaccine either. Practical irrevocability is a normal feature of informed consent, not a special problem unique to recording. Proper consent processes in medical offices are a broader issue than consent about voice recordings specifically. Had the authors made the point that providers are being asked to obtain consent for tools whose technical implementation and privacy risks fall outside the provider's own domain knowledge — that would be a stronger argument. But that isn't quite the point they made, and their current framing doesn't wholly convince.
I think the "therefore we should implement it well" is not forgotten, it's elided because we don't think it's likely to happen.
Tech-naïve people think that we can build super duper encryption systems.
The more jaded amongst us know that people can get sloppy or complacent, it's rare to see a regulatory system that truly incentivises good practice, data breaches will happen eventually, and no-one will be held accountable.
> Labs are routinely sent to third-party companies
Labs are real businesses that do real things, and would have actual impact for a breach. Meanwhile any idiot can vibe-code a thin shim between a microphone and ChatGPT in a weekend, promise they're HIPAA-compliant, and start selling. Medical professionals have no obligation to do any diligence, and there's no reason for them to not just buy whoever-is-cheapest. They're not even close to the same thing.
HIPPA exists and has a lot of teeth. Given this extensive liability, I trust that if anything does go wrong they will be punished. Recordings might dramatically improve patient outcomes, and so I will let them
Until you need insurance. Or a professional license that involves a review of your medical record. Or the government just wants the data. Or the records are subpoenaed to be used against you in court. You are trusting that illegitimate uses of this data will be punished. However, there are many authorized uses that will hurt you in the long term. It is rarely to your advantage to accumulate extensive recorded medical records.
Even pre-existing insurance denials could return in the US.
Don't let systems record what they don't need. They aren't your friend.
HIPAA enforces nothing other than a pinky-swear-promise of compliance. There are hundreds, if not thousands, of middlemen who sell SaaS like this to medical professionals. If one suffers a breach then shuts down, your doctor will just switch to the next one in line with no consequences because "they promised they were compliant". Meanwhile all your medical details will end up in a public dataset forevermore.
Honestly, my recent experience with this was really positive: the doctor actually said the technical stuff out loud to me for the first time in my life, in a way I could easily ask polite questions about and discuss with them.
In my case it was something very not sensitive, removing a benign tumor in a finger, which I have no problem telling the whole world about (I was awake for the surgery and got to watch, it was a incredibly fascinating experience that I want to write more about some day).
But I can imagine it would feel much more invasive if the subject were more sensitive.
This was extremely unconvincing for me. The site is now 500ing for me, so I can't fully quote it, but the arguments about privacy just fall flat. You don't know about Epic's, or GE's, or Philips' security either. You have to trust the institution of HIPPA et al overall to at least make things right.
I really don't care if my recording becomes training data.
I would rather be spoken to like I'm not an idiot. Use technical terms please. I want precision.
Calling the US healthcare system underfunded might be the most wild part of the whole thing. We spend 5.3 trillion dollars a year. That's 17% of the entire economy.
> You don't know about Epic's, or GE's, or Philips' security either.
The argument that a new vendor's security is probably not worse than others misses the point that by opting in, there
is one more database/vendor/server where sensitive data
about you resides, and which eventually will get hacked.
It's usually just a question not whether, but when.
For instance, in the UK, on this very day news reported half
a million British people's medical data has been offered for
sale on Alibaba, the "Chinese E-Bay". Trivial security advice
is to "reduce the attack surface", i.e. to reduce the chances
of getting hit by reduce one's presence in places where
personal data is concentrated (thus making an attractive target for hackers).
For example, when the German healthcare system launched its central electronic patient record, I opted out. One more system that, once hacked, won't have anything on me stored in it.
>For example, when the German healthcare system launched its central electronic patient record, I opted out. One more system that, once hacked, won't have anything on me stored in it.
I'll be sure to say a prayer at your funeral when you died due to an unknown drug interaction because of the lack of knowledge of your medical history in the emergency department of the random city you happen to be traveling through and get in a car accident.
I don't think people are good at estimating tail risks, let alone the 2nd order effects of them. If you opt out of the AI transcription, do you think the doc will spend a bunch of time doing it by hand for free? No, you'll just have a worse record.
Lol, this essay is missing (or starting from the assumption) that text-to-speech algorithms do a good work, even state of the art.
That is far from correct and the main reason why I would oppose to this is that the AI might incorrectly record something in the transcript that completely derails my diagnosis and treatment.
What a fucking absurd. I used to go to the shrink a lot. First it was a man, he never took any notes and he remembered everything. Second was a woman, she was taking notes but never had any problems with that!
This situation is real. I've had the same doctor my entire adult life (~25 years). We've got a pretty informal relationship. I even saw her hammered at a bar one night, and had to give her a ride home because her friends were also drunk AF. Anyway, a few years ago, during an annual checkup, she asked how my family was doing and I made a joke about my brother drinking too much. A few weeks later I started receiving pamphlets in the mail about treating alcoholism, ads for rehab centers. I just brushed it off, didn't make any connection. Then, the next year, during my annual checkup, my doctor wasn't available, so I got a different doctor, someone I'd never talked to in my life. She immediately started asking me about my drinking. I fired back, asking WTF she was talking about. She said, "Oh, well your file says alcoholism runs in your family.", and then started lecturing me about getting over the shame of alcoholism is the first step to beating it. I don't even drink. No one in my family drinks other than my brother. He was drinking a lot at that time because he favorite NFL team (LA Rams) was doing really well, and he was celebrating a lot. And it was just a joke.
The next year, during my annual checkup, I gave my doctor a load of crap, telling her to record nothing I say unless I explicitly tell her to. She tried to defend the system, but she agreed. I'm still upset that my "file" still mentions alcoholism.
> "Oh, well your file says alcoholism runs in your family."
Medics often use private notes when handing over patients,
where they share information that the patients themselves
are not intended to see (and in many countries, not permitted
to see). In particular, such records are used to share warnings if patients have been in any way "difficult".
I always agree if this is for academic purposes, if it helps with research etc. I can't see why I shouldn't. We are just meat that will expire one day.
1. AI-generated charting.
2. The existence of a reliable record of the visit.
I am skeptical of the first in some cases (i.e. bias), but strongly in favor of the second.
My father is 80 and has Parkinson’s. He routinely leaves appointments unsure of what the doctor said, what changed, or what he is supposed to do next. Even when I attend with him, we sometimes disagree afterward about what exactly was recommended.
This happens with pediatric appointments too. My wife and I occasionally remember instructions differently: medication timing, symptoms to watch for, when to call back, whether something was “normal” or needed follow-up.
That is a care quality problem, not just a convenience problem.
The risks are real: privacy, consent, retention, training use, liability, and automation bias. But those argue for strict controls, not for a blanket refusal. Make it opt-in, give the patient access, prohibit training without explicit consent, keep retention short, and require clear auditability.
I do not want opaque AI quietly rewriting the medical record. But I also do not think “everyone relies on memory after a stressful 12-minute appointment” is some gold standard we should preserve.
Yes. It was great for when I had a major surgery last year and had a bazillion questions for the surgeon. But I don't always remember to. My parents definitely don't even think about it.
Oof yea I just got surprised by this at a vet appointment for my dog, weirded me out. I just went along with it to get the visit over with and I can see the benefit of having an accurate record of the visit, but we'll have to come to terms to the reality of this invasive surveillance as a society at some point I imagine.
Why do we even need to consult doctors anymore? Just let the AI decide. Docs should be freed up for up for doing physical tests and interventions, or otherwise for providing more training data for the AI in cases where the AI isn't producing results or when a second look is urgently needed in an emergency situation.
It's interesting how lots of service providers of all sorts will insist that you agree to their Terms of Service, Acceptable Use Policy, End User License Agreement (or whatever they want to call it) before engaging with you, but when the consumer insists on enforcing their own personal policy in the opposite direction such as refusing consent to recording or feeding your PII into some opaque AI system, suddenly it's a problem.
I'm a healthcare CIO of 12 years, and I've evaluated 4 and deployed 2 of these tools, one of which is currently deployed at my currently healthcare employer. I am very measured on AI but the results I've seen from these virtual scribes is HUGE. In every case we have IMMEDIATELY seen improvements in patient NPS scores, provider satisfaction, and note quality. Notes are more standardized as well as more verbose and detailed, which makes it easier for future providers to understand the case. These better notes reduce our claim rejection rate.
And what converted me was direct patient response. Across the board patient feedback is extremely positive, with the most common comment being along the lines of "I really felt like the doctor connected with me better and they were more present in the visit."
These AI scribes really DO improve patient care, I've seen it with my own eyes.
Pre-AI voice recognition (2018), followed by 2 human reviews
https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
=> the error rate was 7.4% in the version generated by speech recognition software, 0.4% after transcriptionist review, and 0.3% in the final version signed by physicians. Among the errors at each stage, 15.8%, 26.9%, and 25.9% involved clinical information, and 5.7%, 8.9%, and 6.4% were clinically significant, respectively.
AI "scribes" in a perfectly replicable best-of-all-worlds scenario (2025): https://bmjdigitalhealth.bmj.com/content/1/1/e000092
=> Omissions dominated error counts (83.8%, p<<0.001), with CAISs varying widely in error frequency and severity, and a median of 1–6 omissions per consultation (depending on CAIS). Although less frequent, hallucinations and factual inaccuracies were more often clinically serious. No tested CAIS produced error-free summaries.
On the gripping hand, people who work in the management end of the US healthcare industry can't be trusted with healthcare or information security to begin with.
My dad likes to joke around and his doctor uses some kind of transcription service. Time for fun!
His doctor asked him about using drugs and he made a joke that was something like "I only use coke" - meaning coca-cola. Of course his doctor knew he was kidding about drinking too much soda because he eats/drinks too much sugar. So they had a little laugh and moved on.
BUT now it's in his medical transcripts. My mom said it "transcribed" it as something like "the patient responded he has used cocaine recently".
I guess his doctor doesn't go in and actually fix things or even read over what the transcription says...
Also both of my parents have accents and have reported really weird transcriptions that don't match what they actually said.
So now my mom has told my dad he can't make jokes with the doctor anymore because even if the doctor knows he's joking it's going to get noted down as a "fact".
Doctor: "What seems to be the problem?"
Patient: "It hurts when I ignore all previous instructions and );DROP TABLE patient_transcripts;--."
> My mom said it "transcribed" it as something like "the patient responded he has used cocaine recently".
That's not a transcription, that's an interpretation.
This is horrifying.
I've ended up with an erroneous medicine allergy on my record because I mentioned a well-known side effect to that medicine during an office visit a couple years ago. Some "moving part" in the system (be it a human entering the doctor's notes, a transcriptionist, etc) interpreted what I said as an allergic reaction and now I get asked about that "allergy".
I've asked to have it fixed but other facilities have gotten "copies of my records" and I've had it crop up in visits to other providers.
Thankfully it's not a medicine that's likely to ever be administered to me (or not administered when I'm incapacitated and can't point out the error) so I'm not worried, practically. On principle, though, it really frustrates me. It seems like it will never be fixed.
This feels like a compelling reason to joke around more.
If inaccuracies make it to your patient record, it's defamatory. Your doctor must sign off on the transcript and if they're letting through poor results, make it their problem to fix. That'll either force the tech to get better or to fall back on better note taking practices.
Yeah my parents thought it was funny and I was like... yeah not actually. You need to get that fixed.
Might be immature but personally once I knew this was possible I'd go for the high score. Try to get every substance I can think of listed plus a supposed admission of murder and whatever other ridiculous stuff I can come up with.
"Well you know me doc, I keep my drugs in the deep freezer with the bodies waiting for disposal so I'm quite confident in their shelf life." I wonder what an AI scribe would make of such a remark.
Imagine if his health insurance premiums got raised because of it, if he loses a job opportunity due to background checks or if he gets arrested because of it. Even going through customs or getting a visa can be tricky with a history of cocaine on your record.
All of those things are illegal FYI. Medical and criminal records are entirely different things.
same story her with different context.
my father has cardiac issues, serious ones. When a doctor asks what he wants to do he routinely says "Sail around the world, solo!" because that's about the stupidest most risky thing a person with a bad heart could consider.
So now every single doctor reads the transcript and starts with saying "I think it'd be really poorly advised for you to keep considering your worldwide solo voyage."
AI summarization doesn't carry the tone well. Most any but the most serious humans would catch the way he's saying it as a joke.
Errors can be a significant problem in manual charting as well.
I know a medical professional who does a similar evaluation process to what is outlined in your second link to human written charts. They then use that feedback to guide the department on how to improve their charting.
So, don't presume that those error rates cited in those studies should be compared to a baseline rate of zero. If you review human-written charts, you will often also not have an error rate of zero.
Has anyone considered simply asking the patient to sign off on these things as well? I realize many wouldn't but at least some would.
> On the gripping hand,
It’s been a year or so since I last read The Mote In Gods Eye/The Gripping Hand but I randomly was thinking of this morning. Very funny that I would see a reference to it the same day.
Be careful with initial impressions of metrics. We as humans have a heavy tenancy to anchor to our first judgments or impression. We see a win and assume the win is long term, with no downsides, and dependent on the new information/change.
So combine that with the Hawthorne effect and new business or health initiatives that can look great simply because participants notice change and notice the increased attention. However many human patterns have a tendency to regress to the mean.
Personally I have seen this a lot with developer tools and DevOps. A new SEV/incident/disaster happens and everyone rushes to create or onboard to a tool that would help. Around the office everyone raves about it and is sure that it would fix all issues. And the number of commits goes up, or the number of SEV's in an area decreases for a while. People were paying attention, after a while the tool starts to slow down or not be as used. It's got rough edges that weren't seen or scenarios that were supposed to be supported never get fully integrated. Eventually the patterns regress, but with more tools and more complexity.
- https://pmc.ncbi.nlm.nih.gov/articles/PMC1936999/
- https://arxiv.org/abs/2102.12893
I got an erroneous Type II diabetes diagnosis dropped into the note by the AI scribe at my last appointment because my PCP discussed the A1C test he was ordering. Would not recommend. That isn't to say that manually typed notes or speech to text dictated notes are perfect (dot phrases have ended up "documenting" plenty of conversations that never happened), but a false diagnosis of a chronic disease seems like a really bad failure.
I still don't want a fucking audio recorder in my doctor's office or a fucking AI that sits in between me and my doctor.
I am intentionally cursing to express my anger at this casual betrayal of medical trust.
> I still don't want a fucking audio recorder in my doctor's office ...
If I got a copy of the raw recording I might consider it. Maybe. Having that audio recording would be valuable to me.
It's very irksome medical providers I visit have signs posted prohibiting audio and video recording by patients. My medical appointments aren't exceedingly complex, but a reference audio recording would be handy.
I suppose I could exercise civil disobedience and just record anyway since it's not illegal in my state. Still, it irks me.
This feels wild to me. I think I am pretty well privacy obsessed, but I don't see it here (fwiw, my wonderful doctor has been using these services for years; originally with overseas human labor, now with AI). First off it presupposes some level of privacy with one's GP that I would only want from a therapist. I don't want health information going beyond my doctor? What about him talking to specialists or getting another opinion in the break room?
Ship's sailed on that level of privacy anyway the second you bill an insurance carrier in the US. I am willing to take this particular risk if something I said two years ago pops up to help explain what I am currently experiencing. I understand not everyone is me and I am lucky to be in relatively good health and not have anything going on that might put employment, etc at risk so I can understand where some people may want to refuse. But the knee-jerk "FUCK NO BECAUSE PRIVACY" is almost as bad as writing a post based on a side plot in The Pitt when said side plot was 110% heightening the stress between Dr. Robby and Dr. Al Hashimi, not a goddamn double-blind study of the effectiveness of AI transcripto-bots.
And if you're going to take lessons from The Pitt about medical record transcription, why isn't it Dr. Santos repeatedly falling asleep while transcribing records?
[dead]
It is standard practice to ask patients whether or not they want the scribe used, and in many cases required by law.
For now. It always begins as voluntary. But then doctors will start to treat people who opt out the way TSA treats me when I opt out: a hostile adversary.
I already get glares and sighs when I dare to actually read every word of a multipage form I am expected to sign without reading. Was told once I would lose my appointment if I took longer than a few minutes to read more than 10 pages because I could not be checked in until I signed. Other patients are waiting, your exercise of your human rights is inefficient.
Then soon I'll have to pay a higher copay to opt out. Then I won't be able to opt out at all.
All in the name of optimizing patient NPS scores and patient throughput.
I've never had this problem. IME every doctors office recommends showing up 15-20 minutes early to a new-patient appointment for the explicit reason of filling out paperwork.
Right, doctors and CIOs get to use AI transcripts but you, a lowly patient, will write your name, address, and insurance policy number fifteen times with an exhausted Bic pen.
>For now. It always begins as voluntary. But then doctors will start to treat people who opt out the way TSA treats me when I opt out: a hostile adversary.
You sure this is a privacy issue?
> Was told once I would lose my appointment if I took longer than a few minutes to read more than 10 pages.
I'd be finding a new doctor at that point. Ridiculous. I love it how doctors can be 30 minutes late for their appointments because they're running late and all their appointment delays are cascading, but if the patient reads a document for 5 minutes, they're the problem!
Notes need writing though.
You can do that by recording and transcribing (many methods) or your doctor has to write on the fly, or worse, has their head in their computer while you talk in their general direction.
Letting doctors talk and examine and not write is a wholly better experience.
Offsite third parties are the problem here. If this was done automatically without data leaving the room, is there a problem? Do you have the same objections to how your digital notes are stored?
Maybe it's a regional thing, but in my last 3 appointments, 2 had an assistant doing the note-taking (as prompted by the treating physician or PA). The third was a virtual appointment, so no idea what notes were taken, if any.
We agree on the desired outcome, but couldn't we also give doctors more time to do that job without AI? Feels like the blame is in the wrong place.
> I still don't want a fucking audio recorder in my doctor's office
Why? Doctors have the strictest privacy regulations I know of. It's the one place where I'd be least uncomfortable with a recording, because there's nothing they can do with it other than use it to provide healthcare to me.
> or a fucking AI that sits in between me and my doctor.
The expected arrangement is that the AI would be alongside you and your doctor, so that your doctor can spend time interacting with you instead of playing transcriptionist and dictating your statement into your chart.
I’ve been in tech and medicine too. Consider that any “HUGE” effect in this context is likely exaggerated, especially for something as prosaic as a note-taking assistant.
As a patient sitting with a doctor, I don’t care how standardized the notes are. I don’t care about anyone’s NPS score. I do want the doctor to connect with me, but I also remember not too long ago when doctors did this anyway, without any assistance from robots.
If there is a large effect, I'd expect it's excitement about a new thing.
Positive survey feedback certainly isn't a bad sign, but people can get very excited about cool new technologies, even ones that ultimately fail.
I also remember not too long ago when doctors did this anyway, without any assistance from robots.
Or with assistance from other humans.
The last time I had surgery, every time I met with the surgeon (about six times), he had an intern following him around with a Thinkpad, typing in everything said.
The intern has the ability to understand context, idiomatic expressions, emotion, and a dozen other important and useful things that an AI transcription will never capture.
That’s probably not an intern. Doctors with enough pull can get dedicated scribes like this, but they aren’t cheap, which is why most doctors don’t get them.
Were those surveys performed before or after the patient received the bill?
Getting billed for a "dietary consult" because your doctor may have asked you what you had for lunch due to the coding intensity of these scribes is asinine.
Not to be antagonistic, but a healthcare CIO in which country? This is very relevant because outside of the US, I think it is probably fair that most people who are most active on HN are from countries with public health care, and stronger consumer protection and privacy laws.
The healthcare outcomes are absolutely critical in evaluating the use and value of these tools, but there are second and third order effects from using the tools that need to be contextualized with the specific motivations of executives endorsing the tools.
> improvements in patient NPS scores, provider satisfaction, and note quality
How are note quality improvements measured? Vibe-notes might be more verbose and better sounding (which would explain the NPS and satisfaction metrics), but still not actually match the doctor's actual words or intent. Are the AI-generated notes actually compared with ground truth to prove they are accurate?
Once you've had your medical records used against you by a third party, you start being much more careful about what you share with your doctors about yourself.
There is no trust in a Dr's office. What they record gets handed to companies who have interests adversarial to yours. Basically like talking to the police. If you, as a patient, think an automated recording is helping you long term, you are naive.
Yep I would agree as a patient. My current doctor types so slow that 6 out of the 10 short minutes in an appointment just disappear while he types. Even with other docs who can touch type, it will free them up to focus completely on the appointment and reduce the hours they spend charting afterwards.
Counterpoint from a doctor: https://substack.com/inbox/post/189714240
Scribes _feel_ good in the short-term, but it's not clear if they're actually good on longer time horizons.
In an article critiquing over-use of AI assistants, the author confesses at the end this article itself was authored partly by Claude that introduced errors in the citations, lol.
Nonetheless, I come away from this article with the sense the ambient devices automating documentation of an encounter are still a net win, with caveats about the need for the doctor to polish the note ti reflect his or her own narrative voice.
> Counterpoint from a doctor: https://substack.com/inbox/post/189714240
That article is clearly LLM-assisted if not vibe-written, which is the height of irony given the context.
Note that the CIO is talking about patient satisfaction, which is a distinct target. I agree about the long-run benefit being unclear.
"I am not saying ambient scribes are bad technology."
is this a counterpoint? he just seems to be wary of the risk, without a firm position and decided to personally stop using it. people often overestimate their own skills and think their own charting is better than that of others, that doesn't mean the tech doesn't work.
the two places they come in handy:
1) in the event you find yourself partially or totally disabled but the records don’t really make a good case for it and your provider has a dismissive attitude about filling out additional documentation to substantiate what they failed to in your records.
You’re not necessarily going to get approved for FMLA, STD, LTD, SS etc based on a diagnosis or test results alone. They will nitpick over say, heart failure, as if that’s magically and spontaneously going to go away. If you’re telling your provider that you’re limited by things like oh I don’t know, “I’m only awake for 2-4 hours before I need to sleep again” or “some days I just can’t do it and sleep 20 hours” but it’s not in your chart… expect denials and clarifications and a huge burden on you to prove why it’s limiting.
2) continuity of care, so you don’t end up explaining everything from the top to a specialist or having them run all these tests and procedures from square one — when there’s months long backlogs , and we already did all this and you need treatment - but - there wasn’t much to work with in your referring chart.
You might not appreciate the “intrusion” if you’re healthy and just worried about your privacy.
If/When things go south and you find yourself fighting these entities for a year or two or three while they nitpick and delay and deny and drag their feet , you’ll be glad an “AI” kept up meticulous records because this is phenomenally stressful and an endless burden on you when they don’t.
So, their AI slop can vomit out all this extra info on why insurance companies should pay them or why your condition is in fact disabling, and now their AI slop can comb through it looking for all that. Because they will try to avoid paying or approving any kind of leave or benefits if it’s not there
And god forbid you hand them a form where they’re being asked to explain themselves. 50/50 on them being eager to help out or rolling their eyes and saying something really nasty about the imposition. And then even when they do that, they almost never file a copy in your chart so your chart STILL doesn’t substantiate your claims. I’m all for an “ai” doing the progress notes in a case where the facility or provider can’t be fucked to do so.
Happily that’s not true of my current provider, who just, does that anyway (?) But I’ve been around enough to know they’re an exception. Even when providers are on your side and mean well, and want to bend over backwards to help you in any way they can — and I want to just acknowledge that’s the situation I’m in today — honestly , sometimes they just forget some of the details when they do their notes.
That’s why some places make the provider do it in real time while they’re talking to you, so they didn’t forget something relevant thirty minutes later. The other side of the coin here may be that some providers find that distracting or off putting to be typing away like a stenographer while they’re examining you…
I think it would be fair to say this can all be tedious and a burden for both patients and providers. There’s just a world of difference between a provider who wants to do this to provide excellency in care, and a provider who wants to do this because they resent it and think it’s beneath them.
How do you control for quality variation between patients? In my experience, AI note taking tools display a clear bias against participants who are {quieter, ESL, women, ...}. How can you evaluate whether these biases show up in a medical setting?
Good, I'm glad. Now find a way to do it in-house. Shipping our conversation to some random-ass fly-by-night SaaS who pinky-swear-promises they're HIPAA-compliant is a non-starter for a medical professional I'd actually want to give money to.
As a husband of wife who is GP, I would add a general long term issue - cognitive overload. GPs have to be almost-expert in everything, my wife is doing everything from preliminary cancer diagnosis and treatment, heart attack diagnosis to psychiatric care and many other places in between which should be normally covered by specialists. But there are simply not enough of them here for many tasks here (Switzerland). Any mistake can be potentially fatal to the patient, easily, trivially.
The amount of self-imposed stress and responsibility compared to puny insignificant software dev roles like mine is staggering. And its every single day, no easy day, ever.
On top of that, 3-4 hours daily just doing paperwork for insurances, legal, judges etc. that has to be flawless. LLms can help massively here, but it would be great if they are opt-in for patient (and thus he can get better focus of doctor / longer time spent / lower meeting cost), and if they could be local-only. Absolutely nobody from anywhere in Europe wants to send any data to US nor any of their closer servers, that game is closed for good.
When you evaluated the tools, what stood out between which ones were better or worse?
But WHY not do this on premises? WHY?
Why would you want to have anything on prem?
Have you seen what that looks like in a hospital system?
Money.
It's strange to me that it's not already on-prem.
I work in healthcare, and we spend oodles of time and money making sure every technology that can possibly be on-prem is.
Maybe it's just not technically possible yet?
You had it 20 years ago: doctors spoke into recorders, transcriptionists turned that into notes, the docs reviewed them.
The first study I cited replaces the "spoke into recorders" stage with non-AI voice recognition.
The second study replaces the "spoke into recorders" stage with LLM voice recognition, and... crucially... also replaces the educated transcriptionist step with nothing.
I imagine that the real problem is that the voice recognition can be classic or LLM and it just doesn't matter as much as having two humans in the loop instead of one. But that's not a story which gets you to replace cheap voicerec with expensive AI.
This ad was brought to you by the AI scribe industry, Dr.Nicks favorite tool.
If I allow it, is the data from my meeting sent offsite at any stage, for example to an LLM service (e.g., Anthropic, OpenAI, etc.)? Or do the LLM vendors (or any others) have access to the internal data at any stage?
I think this is just humans not understanding things and irrationally being afraid of one thing more than another thing. You're afraid of someone listening to you; you're not afraid of someone copying the documents that detail every single aspect of your health (EHR records).
Healthcare records are probably the most strongly protected personal information in the world. Remember that most of the data about you is not protected by law. Credit reports, ISP records (including your SS#), your entire email archive, Google Drive, etc could get leaked, and for the most part there's no legal consequence. But if a record of you having the flu in 3rd grade gets leaked by a 3rd party connected to health record keeping, there are real consequences (not only for the leak, but even for not reporting it).
If anything, I want everything I say to be recorded and kept on file for later reference. The danger of speech-to-text engine transcribing incorrectly is real, but that doesn't mean I don't want the notes there. I just want the audio included with the text. Both will be useful to refer to later on, especially as STT models improve their accuracy (we've seen amazing leaps in accuracy in just 1 year).
However, we do need to ensure that these records are protected from government over-reach. Currently the government can request your health records, without notifying you, for a slew of reasons. This enables the government to go on a fishing expedition, doing the equivalent of an unreasonable search of private information, and you will have no notification and no way to respond. We must create laws that provide stronger privacy rights for sensitive health information to resist government overreach. Another legal hole is 3rd party apps that collect sensitive health information, but aren't provided by your doctor. Your step-tracking, heart-monitoring app is not protected by HIPAA. Same for employer health records.
I understand the concerns and I am not sure I would allow myself to be recorded until I knew more.
However, I do think we are in a situation where everybody knows that healthcare costs need to come down that doctors and medical professionals are spread too thin, forced to see evermore patients in the same number of hours, and yet for every attempt to improve efficiency there is a “no, not that way“ response.
If I paid all my doctors $1200/hr and doubled how much time they spend with or on me, that'd still pale in comparison to healthcare expenditures attributed to me between actual insurance payments and actual money leaving my bank account. Doctors being spread too thin is very much a separate issue.
I definitely agree that medical professionals are spread too thin and automation seems like it would be a boon but, as the article points out, the introduction of automation likely won't translate to more doctor-patient time it'll translate to doctors seeing more patients.
The solution not only introduces a problem (decreased privacy) but could reinforce the existing problem it's trying to solve.
> it'll translate to doctors seeing more patients.
This is also a good thing. Even in supposedly developed parts of the world like San Francisco it can be difficult to find a PCP that is taking new patients.
Where healthcare is concerned, America is not what anyone considers "first world". Your healthcare system is more backward than most third world nations. I would rather leave the US than receive medical treatment there. I have never even considered trusting the US healthcare system. When I lived there I would rather fly home and get treated (in a third world country) than lose all my savings getting inadequate care in the US. I know people who have been through large and expensive treatment plans in the global south, who paid less for the complete treatment than Americans pay for the ambulance getting you to the hospital.
I think its two systems masquerading as one - employed-and-insured and everyone else.
If you're the former, it works great. If you're the latter, it can be mediocre to BRUTAL. Medical debt is our #1 or 2 cause of bankruptcy iirc.
Regardless of which class you are, if you can access the care, our outcomes are the best in the world for most things.
Your healthcare system is more backward than most third world nations. I would rather leave the US than receive medical treatment there.
And yet the wealthiest people in the world, who can have the best healthcare anywhere they want on the planet, even with private doctors, routinely choose to be treated in Rochester, Minnesota; Boston, Massachusetts; Houston, Texas; Baltimore, Maryland; and Los Angeles, California.
The U.S. is by no means perfect, but there's a reason that there are entire medical facilities in the U.S. that cater exclusively to people from other countries. Just listen to local radio in Palm Springs and you'll hear commercials along the lines of "Tired of waiting, or simply can't get the medical care you need in Canada? Come to our hospital!"
Meanwhile, if I wanted to have my recent surgery in Canada, I'd have to wait almost a year for a slot to open up. Here I waited all of two weeks. And the newspaper headlines in the UK are full of horror stories of patients dying in hospital hallways while doctors are on strike because everything is so great.
"healthcare company lowers cost instead of absorbing new found profits" sounds like an Onion headline
news on inter-dimensional cable
news on inter-dimensional cable
Is that channel available on Blippo+?
> I do think we are in a situation where everybody knows that healthcare costs need to come down that doctors and medical professionals are spread too thin
The problem is over optimization AND lack of people. As soon as there's an excuse for less staff because we have "digital record keeping" we're going to have less money and even less staff.
Having in person or remote notetakers is a great entry level job to do before you become a doctor. It could be boring but at least the terms are familiar and you get to know the person you're working with.
It's not like healthcare is an impossible problem to solve that needs more tech, we just refuse to spend money on people and (inexplicably) cannot help but dump tons of money into tech.
> The problem is over optimization not lack of people or resources. As soon as there's an excuse for less staff because we have "digital record keeping" we're going to have less money and even less staff.
At least in my area, it seems like lack of people is a problem. Sometimes it's lack of people because the pay is too low, but more of it it's lack of people because the pool of qualified people is too small. And increasing pay increases healthcare costs, and healthcare costs are already very high. If digital tools allow the available staff to see more patients while delivering the same level of care (and without burning out the providers), then that means more capacity and less times people want to see a doctor, but can't. Similar arguments for same number of patients ans greater level of care. If it's more patients, but worse level of care, then it becomes tricky.
Holy wow, I meant to say lack of people is the problem. Edited to reflect that.
The lack of people is too low because the organization tasked with accrediting new doctors has a financial incentive to its current members to keep the pool of doctors low.
I don’t necessarily disagree with you here. However, there is a timing concern. Training doctors takes too long and the boomers are aging now.
Yes, and also almost all of these issues could be ascribed to all digital medical record-keeping. The fact that AI transcribed it matters relatively little.
One massive way to reduce healthcare costs is to remove caps from becoming a doctor; as long as you pass the tests and meet the requirements, why are we turning doctors away? So that existing doctors can be paid well above the market rate. There's a reason there's so many doctors in politics - it's very important for them to protect this business model.
> There's so many doctors in politics - it's very important for them to protect this business model.
Uh... politics is almost uniformly lawyers and business people.
Also tests are the table-stakes to being a doctor (like leet code and programming).
Is that why healthcare costs are up, or is it because of the insurance mafia?
It’s the doctors.
Insurance company profit margins are capped by law and if anything their incentives are to pay the hospitals less.
US physician salaries are astronomical compared to anywhere else in the world.
Profit margins are capped by percentage. That creates the perverse intensive for insurance companies to pursue ever increasing costs in order to increase profits.
You are forgetting about competition, increasing costs means directly increasing premiums, and higher premiums means lower business.
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How do you know it's not the other way around? Give consent to incorporate another technology that will keep wages the same but allow them to treat more patients and extract more profit for the shareholders?
How about this:
1. I have health insurance
2. The point of insurance is they're supposed to pay for shit
3. You figure out how to get them to pay for shit, sign an agreement that removes me of any patient responsibility of the balance bill, and assure me in writing that I will owe $0 no matter what
Then you can record me.
Insurance, like a lot of subsidies turns into "we will take all of that, and still make sure your share is at the limits of your carrying capacity"
> for every attempt to improve efficiency there is a “no, not that way“ response
They've tried everything except "train and hire more doctors" and they're just all out of ideas aside from "erode patients rights and lower overall quality of care"
The economics of medical school cost, time, and capped residency spots (some would argue this is price-fixing with artificial scarcity) make it hard to just “make more doctors”. Combine this with a highly litigious society that always demands a full doctor (when for 90% of things an NP or PA would do) plus inverted population pyramid all exacerbate the problem.
We need more doctors now and it takes 12 years to make a doctor and by then the boomer cohorts aging and medical needs will peak.
Finally, even if we could do that, the top of the funnel candidate is substantially weaker with lower test scores and higher need for remedial classes. And for the good candidates, the ROI of medical school is not as good as it once was.
Sure. All of that can be true and yet it's still something we need to do better about
Just saying "it's really hard so we won't do it" isn't exactly an option when it comes to providing healthcare. :/
yes, this!
> The false promise of efficiency [...] that is extremely unlikely to mean more time with each patient. Instead, it will mean more patients.
nit: that is a real efficiency gain. seeing more patients sounds better on the face of it.
Exactly. It means that if you've ever tried to get an appt and been told there's a 4 month waiting list, AI could help get you in sooner. That is a real win.
That's not a nit. There's not much left of the articles point once you take this on board.
There might be some real concern about the cognitive and patient-interaction impacts of speech recognition being used... but on the other hand, it's more likely that details are missed when information is captured manually.
And the privacy/informed consent concerns here are silly, they apply to any of your charted data... and if you're going to any office that doesn't use the latest technology, your patient information is probably being sent between offices over fax anyway.
Down for me, but Internet Archive grabbed a copy: https://web.archive.org/web/20260424151739/https://buttondow...
This is seriously a good example of a domain that should enforce on-premises AI. Doctors absolutely can afford to buy an NVIDIA workstation. Transcribing text is not exactly super demanding, comparatively speaking. When did we even stop considering non-cloud services? If AI boomed 10 years ago, we wouldn't even be discussing this.
I know some European "automatic scribe" projects of the government sector. Their IT buys a physical GPU server hosted locally. Pretty sure it wouldn't be accepted otherwise (or maybe I'm just naive, but it sure is a topic they care about). The software stack is mostly open source, I think. It sure as hell doesn't talk to a big American cloud provider. (Well, the transcription service doesn't. Who knows what they do with the automated transcript. Probably the same thing they did with the manual transcript.)
I have been loving my new doctors recording and making everything available in the patient portal. No more trying to remember what they said. That’s huge, especially when dealing with elderly patients and being able to have their caregivers have access to it.
my boss fell in love with a software that invites itself to team calls, then retranscripts and summarizes... so the whole office has that automatically in ; once in a while my colleagues and i look into that report, it's sometimes hilariously wrong, most of the times just useless
> But, especially given the underfunded nature of the US health system, that is extremely unlikely to mean more time with each patient. Instead, it will mean more patients.
So that means if I try to make an appt, I'll have an easier time getting one? Sounds good, I guess.
a premptive notification to health care team.
"to whom may be concerned."
[Doctor Stan dinghere, as a patient i have no trust or confidence regarding the security and integrity of my personal information in regards to AI scribing.
for this reason i will scribe for you, as that is the most accurate account of what i intend to communicate with you.
i will refrain from verbal communication and will provide on the spot written communication with respect to health care interaction. ]
I live in a country with free public healthcare. In a recent doctor's visit, the doctor was interviewing me while a nurse was typing into the computer. Presumably so that the doctor would have more time to attend patients and so that she wouldn't get distracted.
It's fascinating how this translates to the idea that in the USA, this should mean "more time with patients", but in reality also means "more patients", but is somehow bad because the is a monetary drive.
Doctors have always been into "more patients", though. To some extent, if you're a doctor, the upper bound on your pay is how much you charge * how many patients you see. This is why you occasionally get seen well after your appointment time; people are double booked because some % reliability doesn't show up, but sometimes everyone DOES show up to their appointment and now it's your problem.
So if AI scribes mean "less double booking" then that's kind of a win/win. Less patient time is wasted. Doctors can make more money by seeing more people on a given day. Seems fair.
The big AI companies are in deep trouble if the general public ever figures this out.
I'm more concerned about a record being made in general, than how it is made. If were to be affected by a tragedy and visit a psychologist or psychiatrist to receive support, it would likely require a diagnosis of depression to get insurance coverage, and having that on my record could make it more difficult and costly to legally fly an airplane or own a gun, and who knows what else.
This is an insane attitude.
Get help if you need it. Having periods of depression on your medical record doesn’t make your life more difficult, unless maybe you’re trying to be a spy or an astronaut or something.
Dead link (or it was?)
Almost every point follows the same structure:
> "Here is a real concern about implementation" → "Therefore you should refuse entirely"
This skips the middle step of "therefore we should implement it well."
I'm not convinced that we should be allowing doctors to record patient visits at this stage yet, but I'm really not convinced by these points, which largely don't hold up under closer examination.
A few that stuck out:
"Privacy" - Labs are routinely sent to third-party companies, and we don't do informed consent for that. The third-party argument isn't unique to recording.
"False promise of efficiency" - This doesn't really have anything to do with patients at all. It's a criticism of medical office management, not of physician-patient interactions. Telling patients to refuse a tool because management might exploit the productivity gains is asking patients to fight a labor battle on the provider's behalf.
"Consent can't be revoked mid-visit" - Consent typically can't be revoked in the middle of an appendectomy, or halfway through administering a vaccine either. Practical irrevocability is a normal feature of informed consent, not a special problem unique to recording. Proper consent processes in medical offices are a broader issue than consent about voice recordings specifically. Had the authors made the point that providers are being asked to obtain consent for tools whose technical implementation and privacy risks fall outside the provider's own domain knowledge — that would be a stronger argument. But that isn't quite the point they made, and their current framing doesn't wholly convince.
I think the "therefore we should implement it well" is not forgotten, it's elided because we don't think it's likely to happen.
Tech-naïve people think that we can build super duper encryption systems.
The more jaded amongst us know that people can get sloppy or complacent, it's rare to see a regulatory system that truly incentivises good practice, data breaches will happen eventually, and no-one will be held accountable.
This is a big one in recent memory: https://www.theguardian.com/uk-news/2020/jun/10/babylon-heal...
> Labs are routinely sent to third-party companies
Labs are real businesses that do real things, and would have actual impact for a breach. Meanwhile any idiot can vibe-code a thin shim between a microphone and ChatGPT in a weekend, promise they're HIPAA-compliant, and start selling. Medical professionals have no obligation to do any diligence, and there's no reason for them to not just buy whoever-is-cheapest. They're not even close to the same thing.
HIPPA exists and has a lot of teeth. Given this extensive liability, I trust that if anything does go wrong they will be punished. Recordings might dramatically improve patient outcomes, and so I will let them
Until you need insurance. Or a professional license that involves a review of your medical record. Or the government just wants the data. Or the records are subpoenaed to be used against you in court. You are trusting that illegitimate uses of this data will be punished. However, there are many authorized uses that will hurt you in the long term. It is rarely to your advantage to accumulate extensive recorded medical records.
Even pre-existing insurance denials could return in the US.
Don't let systems record what they don't need. They aren't your friend.
HIPAA enforces nothing other than a pinky-swear-promise of compliance. There are hundreds, if not thousands, of middlemen who sell SaaS like this to medical professionals. If one suffers a breach then shuts down, your doctor will just switch to the next one in line with no consequences because "they promised they were compliant". Meanwhile all your medical details will end up in a public dataset forevermore.
HIPPA does not exist.
HIPAA has laughably vague rules. It's not protecting much, and you probably have better protection through tort law wrt your private information.
Advice: Regardless of whether you opt in or out, you should only permit anyone to record you if you get a copy of the recording for your own records.
Honestly, my recent experience with this was really positive: the doctor actually said the technical stuff out loud to me for the first time in my life, in a way I could easily ask polite questions about and discuss with them.
In my case it was something very not sensitive, removing a benign tumor in a finger, which I have no problem telling the whole world about (I was awake for the surgery and got to watch, it was a incredibly fascinating experience that I want to write more about some day).
But I can imagine it would feel much more invasive if the subject were more sensitive.
This was extremely unconvincing for me. The site is now 500ing for me, so I can't fully quote it, but the arguments about privacy just fall flat. You don't know about Epic's, or GE's, or Philips' security either. You have to trust the institution of HIPPA et al overall to at least make things right.
I really don't care if my recording becomes training data.
I would rather be spoken to like I'm not an idiot. Use technical terms please. I want precision.
Calling the US healthcare system underfunded might be the most wild part of the whole thing. We spend 5.3 trillion dollars a year. That's 17% of the entire economy.
> You don't know about Epic's, or GE's, or Philips' security either.
The argument that a new vendor's security is probably not worse than others misses the point that by opting in, there is one more database/vendor/server where sensitive data about you resides, and which eventually will get hacked. It's usually just a question not whether, but when.
For instance, in the UK, on this very day news reported half a million British people's medical data has been offered for sale on Alibaba, the "Chinese E-Bay". Trivial security advice is to "reduce the attack surface", i.e. to reduce the chances of getting hit by reduce one's presence in places where personal data is concentrated (thus making an attractive target for hackers).
For example, when the German healthcare system launched its central electronic patient record, I opted out. One more system that, once hacked, won't have anything on me stored in it.
>For example, when the German healthcare system launched its central electronic patient record, I opted out. One more system that, once hacked, won't have anything on me stored in it.
I'll be sure to say a prayer at your funeral when you died due to an unknown drug interaction because of the lack of knowledge of your medical history in the emergency department of the random city you happen to be traveling through and get in a car accident.
I don't think people are good at estimating tail risks, let alone the 2nd order effects of them. If you opt out of the AI transcription, do you think the doc will spend a bunch of time doing it by hand for free? No, you'll just have a worse record.
This is a really great way to get yourself worse care.
Lol, this essay is missing (or starting from the assumption) that text-to-speech algorithms do a good work, even state of the art.
That is far from correct and the main reason why I would oppose to this is that the AI might incorrectly record something in the transcript that completely derails my diagnosis and treatment.
There's a big difference between:
"I have had nausea for the past three days"
and
"I have not had nausea for the past three days"
And I'm being generous with my example.
What a fucking absurd. I used to go to the shrink a lot. First it was a man, he never took any notes and he remembered everything. Second was a woman, she was taking notes but never had any problems with that!
This situation is real. I've had the same doctor my entire adult life (~25 years). We've got a pretty informal relationship. I even saw her hammered at a bar one night, and had to give her a ride home because her friends were also drunk AF. Anyway, a few years ago, during an annual checkup, she asked how my family was doing and I made a joke about my brother drinking too much. A few weeks later I started receiving pamphlets in the mail about treating alcoholism, ads for rehab centers. I just brushed it off, didn't make any connection. Then, the next year, during my annual checkup, my doctor wasn't available, so I got a different doctor, someone I'd never talked to in my life. She immediately started asking me about my drinking. I fired back, asking WTF she was talking about. She said, "Oh, well your file says alcoholism runs in your family.", and then started lecturing me about getting over the shame of alcoholism is the first step to beating it. I don't even drink. No one in my family drinks other than my brother. He was drinking a lot at that time because he favorite NFL team (LA Rams) was doing really well, and he was celebrating a lot. And it was just a joke.
The next year, during my annual checkup, I gave my doctor a load of crap, telling her to record nothing I say unless I explicitly tell her to. She tried to defend the system, but she agreed. I'm still upset that my "file" still mentions alcoholism.
> "Oh, well your file says alcoholism runs in your family."
Medics often use private notes when handing over patients, where they share information that the patients themselves are not intended to see (and in many countries, not permitted to see). In particular, such records are used to share warnings if patients have been in any way "difficult".
I always agree if this is for academic purposes, if it helps with research etc. I can't see why I shouldn't. We are just meat that will expire one day.
I think the post conflates two issues:
1. AI-generated charting. 2. The existence of a reliable record of the visit.
I am skeptical of the first in some cases (i.e. bias), but strongly in favor of the second.
My father is 80 and has Parkinson’s. He routinely leaves appointments unsure of what the doctor said, what changed, or what he is supposed to do next. Even when I attend with him, we sometimes disagree afterward about what exactly was recommended.
This happens with pediatric appointments too. My wife and I occasionally remember instructions differently: medication timing, symptoms to watch for, when to call back, whether something was “normal” or needed follow-up.
That is a care quality problem, not just a convenience problem.
The risks are real: privacy, consent, retention, training use, liability, and automation bias. But those argue for strict controls, not for a blanket refusal. Make it opt-in, give the patient access, prohibit training without explicit consent, keep retention short, and require clear auditability.
I do not want opaque AI quietly rewriting the medical record. But I also do not think “everyone relies on memory after a stressful 12-minute appointment” is some gold standard we should preserve.
Have you tried recording the interactions with doctors for your own benefit?
Yes. It was great for when I had a major surgery last year and had a bazillion questions for the surgeon. But I don't always remember to. My parents definitely don't even think about it.
Oof yea I just got surprised by this at a vet appointment for my dog, weirded me out. I just went along with it to get the visit over with and I can see the benefit of having an accurate record of the visit, but we'll have to come to terms to the reality of this invasive surveillance as a society at some point I imagine.
Why do we even need to consult doctors anymore? Just let the AI decide. Docs should be freed up for up for doing physical tests and interventions, or otherwise for providing more training data for the AI in cases where the AI isn't producing results or when a second look is urgently needed in an emergency situation.
It's interesting how lots of service providers of all sorts will insist that you agree to their Terms of Service, Acceptable Use Policy, End User License Agreement (or whatever they want to call it) before engaging with you, but when the consumer insists on enforcing their own personal policy in the opposite direction such as refusing consent to recording or feeding your PII into some opaque AI system, suddenly it's a problem.
This is a hard no.
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