Improving Clinical Documentation with Artificial Intelligence: A Systematic Review.

Q3 Medicine Perspectives in health information management / AHIMA, American Health Information Management Association Pub Date : 2024-06-01 eCollection Date: 2024-01-01

Scott W Perkins, Justin C Muste, Taseen Alam, Rishi P Singh

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Abstract

Clinicians dedicate significant time to clinical documentation, incurring opportunity cost. Artificial Intelligence (AI) tools promise to improve documentation quality and efficiency. This systematic review overviews peer-reviewed AI tools to understand how AI may reduce opportunity cost. PubMed, Embase, Scopus, and Web of Science databases were queried for original, English language research studies published during or before July 2024 that report a new development, application, and validation of an AI tool for improving clinical documentation. 129 studies were extracted from 673 candidate studies. AI tools improve documentation by structuring data, annotating notes, evaluating quality, identifying trends, and detecting errors. Other AI-enabled tools assist clinicians in real-time during office visits, but moderate accuracy precludes broad implementation. While a highly accurate end-to-end AI documentation assistant is not currently reported in peer-reviewed literature, existing techniques such as structuring data offer targeted improvements to clinical documentation workflows.

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用人工智能改进临床文献：系统综述。

临床医生投入大量时间在临床文件上，产生机会成本。人工智能（AI）工具有望提高文档的质量和效率。本系统综述概述了同行评审的人工智能工具，以了解人工智能如何降低机会成本。在PubMed、Embase、Scopus和Web of Science数据库中查询了2024年7月或之前发表的原创英语研究报告，这些研究报告报告了用于改进临床文档的人工智能工具的新开发、应用和验证。从673项候选研究中提取129项研究。人工智能工具通过结构化数据、注释注释、评估质量、识别趋势和检测错误来改进文档。其他支持人工智能的工具在诊所就诊期间实时协助临床医生，但准确性适中，妨碍了广泛实施。虽然高度精确的端到端人工智能文档助手目前还没有在同行评审的文献中报道，但现有的技术，如结构化数据，为临床文档工作流程提供了有针对性的改进。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Perspectives in health information management / AHIMA, American Health Information Management Association Medicine-Medicine (all)

CiteScore

1.90

自引率

0.00%

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期刊介绍： Perspectives in Health Information Management is a scholarly, peer-reviewed research journal whose mission is to advance health information management practice and to encourage interdisciplinary collaboration between HIM professionals and others in disciplines supporting the advancement of the management of health information. The primary focus is to promote the linkage of practice, education, and research and to provide contributions to the understanding or improvement of health information management processes and outcomes.