With 13 locations in Indiana, OrthoIndy is one of the largest orthopedic practices in the U.S. and is the official orthopedic provider for the Indiana Pacers and the Indiana Fever. The practice also provides care for several collegiate sports programs.

THE PROBLEM

Many of the practice's physicians were spending a considerable number of evening and weekend hours on their charting. This was often two to three hours of charting after-hours for every day of seeing patients in the clinic. This was impacting their health and wellbeing, and depleting them of time for themselves and their families.

Also, when physicians fall behind on charting, it means the practice is not completing all of its back office responsibilities in a timely fashion, including insurance claims submission and billing. This has a downstream impact on business operations. It also can become difficult for physicians to recall all of the details of a patient encounter days after the fact, which can translate into documentation that is less comprehensive than desired.

Further, when physicians have to interact with the electronic health record system and choose from pick lists, checkboxes and other templated content, it can be challenging to achieve a true picture of the patient. Many of the practice's physicians said their notes did not have the color and clarity they wanted, especially when they are looking back at a patient's record in preparation for a follow-up visit. The practice's EHR really is designed to support billing, coding and insurance, not care delivery.

"OrthoIndy has always provided our physicians with documentation support," said Dr. Timothy Dicke, president and CEO of OrthoIndy. "We never wanted our physicians to carry the documentation burden on their own or feel like data entry clerks, which is the reality of many physicians across the county. 

"Our physicians feel that better work-life balance is the greatest benefit of all, and in their estimation, the value is immeasurable."

Dr. Timothy Dicke, OrthoIndy

"Some of our physicians had been using basic speech recognition software like Dragon in conjunction with the EHR. Some had been using traditional dictation in combination with a transcription service, while others had a live scribe in the exam room documenting encounters in real time," he added.

However, none of these solutions are necessarily the most efficient, reliable or cost-effective. They all have their strengths and weaknesses, but overall, none are truly ideal, Dicke said.

PROPOSAL

IT vendor Saykara offers a technology rooted in artificial intelligence that essentially promised OrthoIndy to automate the process of producing a structured note. The vendor referred to it as an "AI mobile assistant" for physicians.

The promise was this: Any physician who used Kara (the name of the AI mobile assistant) would no longer have to bear the burden of after-hours charting. Kara would do their charting for them, based on audio from inside the exam room – from conversations between the physician and the patient – or from brief reflective summaries provided by the physician, post-encounter.

The physician would need only review and sign off on the note in the EHR. The reason the Saykara technology was so intriguing to OrthoIndy was the promise of removing the physician from any hands-on documentation.

MEETING THE CHALLENGE

Dicke was one of the first physicians at OrthoIndy to test-pilot Kara, along with Dr. Mihir Patel, another of the practice's orthopedic surgeons.

"Mihir is a big proponent of digital health technology and its ability to be transformative," Dicke said. "He was integral to our adoption of the Saykara solution. Mihir and I very quickly experienced success with Saykara, and it has since been adopted by physicians all across our organization."

In terms of how physicians use it, they access the Kara app on their iPhones. It brings up the physician's patient lists for the day, and the doctors just tap a patient's name and talk. They can use it ambiently during an encounter, either in the exam room or during a telehealth visit. They just turn it on and the app records the conversation with the patient.

The physicians also can use it post-encounter. Again, they just tap a patient's name and dictate a brief reflective summary, which may take anywhere from 30 seconds to a couple of minutes. They do not have to use any specific commands or instructions. The typical voice assistant behavior, like one would see with Alexa or Siri, is not required. With Kara, a physician simply talks.

"We also don't have to insert data into templates and don't have to tell the app where in the EHR to put the data," Dicke explained. "We can place orders through the app, we can arrange referrals, we can prescribe meds, and the technology does the rest. It produces a fully structured note, which goes directly into our Allscripts electronic health record."

Everything winds up where it should be in the EHR, both structured and unstructured data, he added. Physicians do not have to do any of the typical EHR work. Kara does it for them. Physicians just review it in the EHR and sign off. Saykara provides a person who is in the loop to review data before the data is input into the EHR in order to make sure it is accurate.

The Saykara technology works with OrthoIndy's Allscripts EHR. It pulls patient lists for the day, and, when the AI is done capturing, interpreting and transforming the data from either an ambient conversation or a reflective summarization, the data is input into the patient's chart in the EHR. This includes both structured and unstructured data.

RESULTS

"Kara has completely eliminated after-hours charting," Dicke stated. "Physicians using this solution are no longer spending evening and weekends catching up on charting. For many physicians, this was tantamount to two to three hours for every day of seeing patients in the clinic.

"The solution has had a very positive impact on work-life balance," he continued. "Many have said they feel more relaxed with their patients, they have more time to spend with their patients, and they no longer experience the anxiety they used to feel from the burden of the documentation. This is possible because the physicians using Kara no longer have to interact with the EHR or do manual data entry."

They don't have to use speech recognition software that requires that they be at a computer and inside the EHR. And for those who used to dictate their notes, they no longer have to wait for the transcription and spend time editing it.

Saykara conducted some before-and-after data comparisons and found that physicians using Kara have been able to increase the number of new patients they see by 20%, Dicke noted. This has been possible because of the time savings from not having to do the level of hands-on documentation work they had been doing previously, he added.

The vendor also found the quality of notes, in terms of note completeness and accuracy, has increased by 25% with Kara, Dicke said.

"Using the Kara app removes the need for physicians to interact with templated content, pick lists and checkboxes, which allows for more comprehensive and contextualized notes," he said. "The artificial intelligence understands the physician's style and learns over time with every new encounter. This allows the solution to become more adept at capturing and interpreting what the physician is saying. The structured notes Kara produces are both detailed and accurate."

ADVICE FOR OTHERS

Dicke advises his peers on using this kind of technology, noting that "artificial intelligence holds a lot of promise in helping physicians be more effective and efficient, and [in] reducing both the cognitive burden and the documentation burden."

The ability of AI to learn over time "means we will continue to gain more value from it," he said. "The ROI is there. Although the increase in work-life balance is more qualitative than quantitative, I know our physicians feel that better work-life balance is the greatest benefit of all. And, in their estimation, the value is immeasurable."

It's also fair to say that the current pandemic is bringing a greater level of attention to physician burnout, and the concerns are very real, he explained.

"As a country and as a global community, we are seeing increases in physician suicide rates and increases in the number of physicians quitting practice," said Dicke. "There are myriad contributing factors, but certainly the documentation burden is among them. Any healthcare organization looking to address this issue is well advised to consider this kind of AI solution."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.