The Truth About Using Technology to Save Time on Clinical Notes

Want to know whether EHRs and AI software tools can really speed up medical documentation? We cover everything you need to know in this in-depth article.

For more than a decade, we’ve been hearing promises about how electronic health record (EHR) software is going to slash the time healthcare professionals spend on clinical notes.

However, as you may have already experienced—the truth rarely lives up to the hype.

The fact is, while there are instances where EHRs can save time on documentation, difficult-to-use software systems are still identified as one of the most stressful aspects of delivering patient care.

The American Medical Association calls this “The EHR Problem,” citing frequent surveys that identify EHR challenges as a primary contributing factor to physician burnout.

Lately, with the advent of Chat GPT and AI-powered software tools, healthcare clinicians are increasingly being told that AI can solve the difficulty so many of us face in balancing administrative requirements with our work and personal lives.

Now, we’ll freely admit that here at Heidi Health, we’re on the side of the AI supporters.

In our opinion, AI-powered clinical notes software products, like our AI Medical Scribe, reduce administrative burden for healthcare professionals in a way EHRs and medical transcription simply can’t match.

However, we know that every clinician’s needs are different. So, to help you make an informed judgment about using AI for your clinical notes, we’ll unpack everything you need to know in this article.

Why Clinical Notes?

You have to write a lot of different things as a healthcare clinician. 

Emails, referral letters, reports, ward round summaries, presentations, and project updates are just a few of the things that come up regularly, in addition to your standard progress note or clinic note after seeing each patient.

All of these pieces of medical documentation are important. But, in the overall hierarchy, it’s the clinical notes that go into a patient’s medical record that stand above all else.

Furthermore, for most of us, the bulk of our administration time is spent on clinical note taking.

The Importance of Medical Documentation

Clinical notes fulfill 3 main purposes within the healthcare system.

1. Communication

At its core, a patient’s medical record is a communication tool that helps everyone involved in an individual’s care to work collaboratively and avoid life-threatening mistakes.

Within a clinic or hospital, the medical notes stored on file enable members of the multi-disciplinary team to work together efficiently, without having to be in the same room as each other or continually phoning for regular progress updates.

For patients who require care from multiple providers, clinical documentation enables the efficient sharing of information between providers. This is especially crucial in an emergency setting, such as obtaining a medication list or discharge summary when a patient arrives in the ER.

Finally, in an effort to better understand and direct their care, consumers are increasingly being proactive about obtaining copies of their own clinical documentation.

2. Legal

Any healthcare professional who’s been through a medicolegal issue knows the crucial importance of clinical notes.

Other forms of medical documentation can be considered in legal matters. However, the file—and in particular progress notes and clinic notes—are generally considered the closest thing to a single source of truth there is.

We’ve all heard the saying, “If it’s not written down it didn’t happen.” What this really means is, “If it’s not on the medical record it didn’t happen.”

Aside from medicolegal matters, reliably producing accurate clinical documentation for all patient encounters is usually a requirement of registration for most practitioners.

3. Financial

On a daily basis, it might seem that insurance claims and coding records are the most influential types of medical documentation. However, when following best practices, these are simply reflections of the clinical documentation on file.

As with legal matters, the final source of truth for financial reimbursement in healthcare is always the clinical record (in both the public and private sectors).

When a funding body or insurer audits a healthcare practice or individual clinician, they will almost always drill down to the level of individual medical records, checking to see that these match claims for reimbursement and reports on care provided.

The #1 Challenge with Clinical Documentation

Most challenges with clinical note taking come down to one common factor—time.

We all understand the importance of good clinical documentation. But, when you spend the entire day juggling an endless list of competing priorities, it can be hard to consistently give every clinic note the care and attention it deserves (while maintaining some semblance of a healthy work-life balance). 

Some of the ways time constraints with clinical documentation show up are:

• Writing medical notes after hours
• Not including enough detail in a progress note
• Accidentally omitting a key part of a clinic note (like plan, treatment provided, or diagnoses)
• Stress and anxiety around always feeling behind on your notes
• Writing in a way that is not coherent enough for others to follow

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Modern EHRs have attempted to alleviate most of these challenges in one way or another, with varying success.

An Overview of Medical Documentation Software

Comprehensive electronic health records (EHRs) are the most recognisable type of clinical documentation software.

Promising to streamline all aspects of clinical documentation, modern EHRs can handle everything from intake to progress notes to referrals. They also often help streamline insurance claims, appointment scheduling, and other important administrative tasks.

Many clinicians operate just with an EHR and some paper-based recording. However, due to unique clinical needs, a desire to reduce documentation time, or dissatisfaction with the functionality of EHRs, some practitioners also utilize stand-alone clinical notes software products and apps, such as:

• Medical transcription programs
• Observation recording and checklist apps (common for some allied health professionals)
• DIctation and voice-to-text products
• Online clinical note template libraries

Can EHRs and Clinical Notes Software Products Save Time?

Compared to traditional paper and pen medical documentation, most clinic note software will save you some time.

This is typically achieved by:

Auto-populating data - Automatically adding things like patient demographics, diagnoses, billing information, and details from previous appointments to a progress note, referral letter, insurance claim, or other type of clinic note.

Pre-made templates - Most medical documentation software includes ready-to-use clinical notes templates. These allow the clinician to simply fill in details under each section during the interview. Common examples are a SOAP clinical notes template and an intake form template.

Flexible access - Healthcare practitioners often work in settings outside of a traditional clinic. In these cases, waiting until you are back on-site to write notes can make keeping up with documentation difficult. Most modern EHRs enable staff to securely write notes from any location, including while on home visits via a tablet or laptop.

Easy sharing - Clinical documentation software saves time on sharing information within organizations because all authorized staff have on-demand access to a patient's medical record. Good products also make it easy to share notes outside an organization, with features like easily downloading a discharge summary or referral letter to send to another clinician.

Pitfalls of Poorly Designed Software

Unfortunately, despite the many potential time-saving features in clinical documentation software, most clinicians still feel like they are fighting a constant uphill battle to keep up with documentation.

One of the reasons is that EHRs often aren’t very user-friendly. This means that the majority of time saved on writing a clinic note can subsequently be lost in navigating clunky, unintuitive systems.

For example, writing a progress note in a paper file simply involves opening the file, finding the progress notes section, and then writing your note. 

However, in a poorly designed EHR, you might have to:

• Login
• Navigate through a dozen alerts and notifications
• Search for the right patient
• Select a template
• Review auto-populated data
• Make selections from various drop-down boxes
• Enter your note
• Save your note 

What Traditional Software Products Can’t Do

Unintuitiveness aside, there are some substantial limitations in what traditional medical documentation software products can do.

These will vary according to each product. But the 5 main limitations are:

1. Can not eliminate duplication

Many clinical encounters require the production of several different documents. For example, a physiotherapist seeing a patient for post-surgery rehabilitation would need to write a clinical note for the file, a rehab program for the patient, and a letter to the referring physician. With traditional medical documentation software products, each of these documents must be created from scratch (aside from perhaps some basic auto-populating data).

2. Dictation is limited to transcripts 

Voice-to-text software has improved a lot in recent years. However, at best, it can only provide a verbatim transcript of what was said during an interview. Most practitioners find this doesn’t actually save time when writing a clinic note, because the transcript still requires heavy editing, sorting, and formatting.

3. Unable to sort information 

This is the reason duplication is unavoidable. Because traditional medical documentation software can’t distinguish between information types, it can not streamline different administration tasks. When documenting an interview, the clinician must still manually sort diagnostic information, treatment plans, billing information, and more.

4. Minimal personalization

Anyone who’s used a conventional EHR knows you can’t really make it “yours.” At best, you can save some customized templates and a current list of current patients. On the whole, it is you that needs to fit in with the EHR, rather than the other way around. 

5. Improvement requires investment

Like all software, creating traditional clinical notes products is an iterative process. Clinicians use a product in its current state, identify flaws or shortcomings, then report these to the software provider, hoping that a fix will be forthcoming. Because of the high cost involved in upgrading software systems, clinicians are often left using a sub-par product for extended periods of time.

For medical software to truly move the needle for healthcare professionals, we must find solutions that overcome the current limitations of traditional software products.

While there is still significant room for growth and development, AI-powered clinical notes software currently offers the best hope for making a meaningful difference in the administrative burden faced by healthcare practitioners.

The Current State of AI for Clinical Documentation

Utilizing large language models (LLMs; the technology behind ChatGPT) and machine learning, clinical notes AI products like Heidi’s Medical Scribe are already helping clinicians save hours each day on their documentation time. 

The best way of understanding how a tool like an AI progress note generator reduces administrative burden, is to examine what it does to overcome the limitations of traditional software products.

Time-Saving Capabilities of AI Medical Documentation Software

Below are examples of how the capabilities of Heidi can significantly reduce the time clinicians spend on clinical notes and medical documentation.

Get the Best of Both Worlds (at no additional cost)

For most clinicians (especially those working at large practices or in hospital settings), using an EHR isn’t optional.

Even if you were to write your notes by hand, it’s almost certain you would still need to enter a significant amount of information for each patient encounter into a digital medical record. 

What’s more, EHRs do have some features that can legitimately save you time on documentation and administration.

Fortunately, it isn’t an “either-or” choice between using AI medical documentation software and traditional EHRs to write clinical notes. 

Every clinician can, and probably should, use both.

With this in mind, we decided to make Heidi free for all clinicians.

We don’t want limited resources or a lack of organizational will to stop clinicians from accessing a tool that can give them more time to focus on important work (and getting to go home on time).

Sign up today and find out just how much faster writing clinical notes is with Heidi.