10 Tips for Getting Started with AI Scribe and EHR

Teleneurology involves a transformation of how medical records are handled. Using AI scribes together with Electronic Health Records (EHRs) helps healthcare providers minimize patient records and lowers their workload so they can focus more on their patients.

Transforming this technology into daily clinical use requires significant efforts. The implementation requires addressing technical difficulties while healthcare staff need time to adapt, and doctors should introduce workflow modifications.

A transition plan including ten practical strategies draws from both practical experiences and data-based insights along with useful insights.

1.Practical Training

Practical training serves as a connection between doubting professionals and total understanding of the content.

The Challenge

Doctors typically doubt the value of AI tools because they are unfamiliar with their functionality. Stanford Medicine's 2023 research shows that 40% of physicians resist AI scribe implementation, primarily due to suspected systemic errors and operational disturbances.

The Solution

1.     Multiplayer role-playing scenarios should include diverse patient cases, which include elderly patients with multiple medical issues and young patients needing immunizations. With Freed.ai, providers obtain the ability to submit their simulation recordings, which help the AI system learn medical vocabulary specific to their field.

2.     To develop AI documentation abilities, organizations should work with artificial intelligence transcription vendors who provide direct training events. Through its program called “AI Documentation Days,” Nuance's Dragon Medical One gives healthcare providers opportunities to practice real-time medical documentation after receiving instant feedback.

3.     The system assesses skills through two metrics: the time needed to generate notes and the number of editing actions after physician reporting sessions. Medical staff at UC San Diego Health decreased their documentation period by 27% after obtaining targeted training for eight weeks.

Pitfall to Avoid: Neglecting non-clinical staff. Both the front desk workforce needs patient consent form management training, and IT professionals require training for integration problem resolution.

2.EHR Integration

The Challenge

When systems function independently from each other, they require organizations to perform double work. According to KLAS Research data, 33% of medical staff experience delays of more than 15 minutes while moving between their EHR and various supplementary tools.

The Solution

1.     Prior to buying an AI scribe system, verify that it can operate with your EHR platform. These two systems integrate with Epic and Cerner to demonstrate their ability to generate patient history population and order set recommendations for evidence-based practice during office visits.

2.     The AI system must possess the ability to retrieve data from EHR systems while ongoing consultative sessions. The AI-powered Nabla scribe at Massachusetts General Hospital performs real-time prescription evaluation, which helps prevent medication errors by comparing selected drugs against patient allergies.

3.     You should collaborate with vendors to develop specific APIs that integrate with legacy EHR systems. The AI-controlled clinic in the Midwest successfully developed an API to connect its AI software with MediTech, making the data entry process 90% more efficient.

3. Strategic Communication

Strategic Communication Involves Learning to Understand the AI’s Mode of Operation

The Challenge

AI scripting software has difficulty interpreting statements of ambiguous content. The research published in the Journal of Medical Internet Research showed 18% of AI notes produced inaccurate symptom documentation because physicians used ambiguous verbalization.

The Solution

1.     The implementation of precise command functions by replacing ordinary commands with straightforward instructions.

2.     The patient should receive nightly atorvastatin 20 mg prescribed when LDL exceeds 190 mg/dL.

3.     The patient needs a colonoscopy appointment for six months because of their CRC family history.

4.     Focal placement of essential terms “allergy,” “contraindication,” or “urgent referral” in the text enables instant recognition of critical items.

5.     Use medical terminology instead of colloquial expressions because AI has difficulty in understanding informal language. The patient experienced angina pectoris lasting five minutes, according to his reports.

6.     You should create a specialized glossary containing medical terms from different specialties, such as "CHF exacerbation," for heart medicine professionals to maintain consistent team terminology.

4.Human-AI Collaboration

The Challenge

Overreliance on AI introduces risks. The AI scribe working at a Texas urgent care chain incorrectly heard “no history of MI” as “knows history of MI,” leading to a potential treatment mistake.

The Solution

Dual-Layer Review:

·        The AI system produces its initial draft note for documentation purposes during patient sessions.

·        After the first draft, AI creates a note, and a healthcare professional conducts another review and edit before the end of the 24-hour period. Through this method, Cleveland Clinic decreased errors by 62%.

·        Sunoh.ai enables providers to customize their templates by indicating critical risk areas such as “Patient denies suicidal ideation,” which appears in psychiatry notes.

·        The implementation of bias audits involves ongoing tests to identify racial, gender, and age-related biases that occur throughout the AI output process. The tool should be designed specifically for female patients and seniors to prevent omissions of pain symptoms.

5. Structured Implementation

Structured implementation phases help distribution periods run smoothly while boosting overall acceptance among staff members.

The Challenge

Organization-wide launches often fail. A review in the Harvard Business Review demonstrates that employee resistance leads to project failure when achieving system-wide AI adoption.

The Solution

·        The initiative starts by implementing testing phases with providers who have favorable perceptions of technology within departments that pose minimal risks for adverse outcomes such as dermatology and primary care. The dermatology pilot at Johns Hopkins University resulted in 40% shorter documentation durations, which motivated staff members to champion AI throughout the facility.

·        Champion Networks: Identify early adopters to mentor peers. Through its training initiative using 15 hospital workers as “AI ambassadors,” the Florida hospital system accelerated adoption beyond 200% marks.

·        The organization should establish regular feedback forums for medical professionals to share their obstacles with the system. The physician working in pediatrics stated that the AI system frequently eliminated correct classifications of "well-child visit" into "sick visit" during use; the problem was resolved following training of the system with 50 example clinical inputs.

6. Environmental Optimization

The Challenge

According to the Journal of Clinical Informatics study published in 2024, background noise can decrease AI accuracy rates by thirty percentage points.

The Solution

·        In the exam areas, install the Jabra Speak2 75 microphone devices because they efficiently block unnecessary background sounds.

·        Put "AI Recording in Progress" signs where patients can see them to reduce disturbances.

·        Medical staff at NYU Langone implement redundancy plans by repeating important information to maintain correct data transmission during noisy emergency room conditions (e.g., “Patient's glucose reaches 450 mg/dL—spell G-L-U-C-O-S-E”).

7.Privacy by Design

The Challenge

Patients fear data misuse. Research by Pew Research shows that 58% of people disapprove of AI scribes because of privacy issues.

The Solution

·        The patient intake form should include this statement: “Our use of AI technology benefits patient care.” May we record this visit?” Mayo Clinic applied their approach to consent acquisition and achieved success with an acceptance rate of 82%.

·        Data Encryption: Choose vendors with AES-256 encryption and HIPAA-compliant cloud storage.

·        The system allows patients to access AI-generated notes through portals that include MyChart. UCLA Health discovered that 67 percent of patients who reviewed their records through the system detected errors, which they then corrected correctly.

8.Specialty-Specific Customization

The Challenge

Generic templates hinder efficiency. The orthopedic surgeon highlighted how AI failed to detect essential ACL tear details, which made him restart his note creation from scratch.

The Solution

Tailored Workflows:

·        Cardiology: Auto-insert ejection fractions, stress test results. Medical staff in oncology can use the system to track chemotherapy protocols as well as oncologic genetic data.

·        Macro Shortcuts: Create “/dm2” to auto-expand to “Type 2 diabetes mellitus with HbA1c 8.2%.” The templates provided by Augmedix help physicians save 60% of their time during customization as part of their vendor partnership.

9.Troubleshooting Playbooks

The Challenge

Technical glitches erode trust. The Phoenix-based clinic discontinued its AI scribe because sync failures between EHR and AI systems kept occurring.

The Solution

·        Documentation of standard system problems exists in the Error Libraries to help users resolve common issues.

·        The AI system needs training with different staff accents through recorded audio from various employees.

·        Reboot the AI-EHR bridge if the EHR freezes, and the staff must manually save notes.

·        A team of IT specialists known as Rapid Response Teams must be prepared to tackle problems during designated response times of 15 minutes.

10.Continuous Evolution

The Challenge

Static systems become obsolete. An AI model needs regular system updates in order to maintain its accuracy level.

The Solution

·        A quarterly audit system should compare errors alongside denial data as well as collect feedback from medical staff to assess performance.

·        Survey questions asking patients about provider-rushed behavior provide an indirect way to monitor AI system influence on healthcare quality.

·        Vendor Roadmaps: Demand biannual updates. The language capabilities of Suki AI have expanded to 15 different languages, which improves its practical value.

AI Scribes and the Future of Healthcare

AI-EHR integration will experience further revolution through emerging technology trends:

·        Computer systems using historical EHR information will prepare pre-appointment summaries, which decrease clinical documentation times by 5–7 minutes each session.

·        Future tools will use voice plus facial expressions together with gestures to spot non-verbal signs when analyzing patient interactions (for example, patient anxiety).

·        The healthcare tool AMIE, developed by Google, will enable AI scribes to extend their services to the global regions that currently lack specialist physicians.