One of the more interesting challenges that health system IT executives face today is evaluating and prioritizing new clinical applications for AI. Among the rapidly expanding number of innovations covering nearly every aspect of health system clinical and administrative operations, ambient AI is one of the more compelling technologies because of the immediate and longer-term value it provides. In our experience, the process of implementing an ambient AI solution can also serve as a model for testing and deploying other advanced intelligence solutions.

Our journey to ambient AI

We first considered ambient AI technology after Nuance Communications introduced its DAX system in late 2019 to mitigate physician burnout by reducing clinical documentation workloads. We were generally familiar with the Nuance system because it uses speech processing technology that evolved from its Dragon Medical One software used by physicians at SCL Health and other health systems. In mid-2021, we began deploying Nuance’s DAX system at our $2.8 billion faith-based, nonprofit healthcare organization serving patients in Colorado, Montana and Kansas.*

The tool works automatically in the background, securely capturing conversations between clinicians and patients during in-person or telehealth visits. The keyboard and screen that typically require the physician’s attention are replaced by an unobtrusive, low-cost device like a smartphone or tablet. DAX records and converts the interaction into AI-generated clinical notes which are routed through a quality review process to ensure accuracy. The system continuously learns and becomes increasingly accurate and efficient with each word.

The resulting documentation is presented to clinicians to quickly and easily review and approve in the EHR system as part of their day-to-day workflow. If a physician has any questions about the generated notes, the recorded interaction is available for review.

Goals and deployment plan

We first defined how the system aligned with our strategic goals for improving physician satisfaction, expanding digital patient engagement, and using EHR system as a platform for innovation. We also viewed our implementation of the Nuance system as a critical opportunity to work with a technology vendor as a trusted partner vs. following the traditional buyer-supplier model.

We then identified cohorts of providers as early adopters. We included specialties best suited for DAX usage including cardiology, orthopedics, and other clinical areas with relatively standardized terminology and exam procedures. We also incorporated family medicine providers to assess the system’s ability to learn more diverse vocabulary and patient scenarios. In addition, physician need was determined by analyzing signal data from our Epic EHR showing providers who spent more time working on documentation either during or after clinic hours.

We narrowed an initial target list of 50 providers to 25, 10 of whom declined to participate in the initial deployment for various reasons. Deployment began in May, followed in September by an assessment of system performance in a total of 5,426 patient encounters.

AI outcomes and benefits

We evaluated the AI system’s performance based on:

• Increased operational efficiency through reduced documentation time, increased throughput, and greater access to care:
  • An average of 13minutes saved per encounter (family medicine)
  • A 50% reduction in physician documentation time
  • An average of 1.7 appointments added per clinic day (family medicine)

• Higher clinician satisfaction from reduced administrative workloads and higher quality documentation:
  • 50% reduction in feelings of burnout and fatigue
  • 60% of physicians were satisfied with documentation turnaround time
  • 60% would be disappointed if they no longer had access to this system
  • 70% of physicians say the system has improved documentation quality

• Better financial outcomes through time savings and incrementally higher revenue from more accurate clinical documentation and appropriate coding:
  • $104,537 in annual added value through time-saving per provider (family medicine)

• Improved provider and patient experiences with clinicians feeling more rested, focused, and engaged with patients, and patients having positive experiences in encounters with physicians using AI. Patients familiar with consumer voice applications felt comfortable with the system and felt they had chosen modern, well-equipped providers and facilities:
  • 80% overall increase in the quality of the overall patient experience
  • 60% of physicians report higher-quality patient interactions
  • 70% of patients report an increase in provider face time

Additionally, documentation turnaround time steadily declined from 5.26 hours in May to 2.19 hours in September, while utilization of the system increased to 60% of scheduled appointments.

Today, we have a fully voice-enabled and ambient exam room environment using this AI technology. The system frees clinicians to focus on their patients, gives them back time in their day, and enables them to practice at the top of their license. From an IT perspective, the system reduces complexity because it enables a single cloud platform and single workflow solution for all clinical environments.

Implementing ambient AI represents an opportunity to establish partnerships with IT vendors.

Best practices and outlook

Implementing ambient AI represents an opportunity to establish partnerships with IT vendors. We worked closely with Nuance, collaborating on everything from iterative system changes and improvements to pricing, and making service level agreements and shared risk an integral part of our relationship. In addition, Nuance has consistently shown a willingness and ability to respond to user feedback. The DAX systems we use today are small, inexpensive devices that replaced the bulky, wall-mounted, first-generation designs introduced in 2019.

We also worked closely with physicians who understood the challenges and opportunities of implementing ambient AI to empower them as technology champions for their peers.

Looking ahead, we plan to offer DAX to clinicians in other clinical areas through a repeatable process of expanding small, targeted deployments to more users, incorporating learnings from each one to maximize the value of our investment. We see this process as a transferable model to future implementations of advanced technologies.

* SCL Health and Intermountain Healthcare are planning to merge in early 2022 and form a 33-hospital system with more than 58,000 caregivers across six states and provide about one million people with health insurance.

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The healthcare industry is constantly changing in ways that healthcare providers cannot control.  Changes in payor billing requirements and payment models, along with fluctuations in patient demographics and health conditions can cause struggles for organizations with poor processes. Successful organizations must optimize their controllable procedures and create the bandwidth to address industry changes they simply cannot control. The use of technology to maintain financial stability is essential in this ever-changing industry.

Front end revenue cycle begins with patient registration and ends once payments are collected. Obtaining the correct insurance information and patient health profile upfront allows a company to develop the appropriate plan of care tailored for that specific individual. Many patients need health care right now and time is of the essence when verifying benefits and communicating patient financial responsibilities. Utilizing technology to verify eligibility automatically decreases the chance of human error, while providing faster results. Some insurance providers only authorize a certain level of care or visit count, depending on the patient’s health condition. Setting up system holds in the EMR will ensure that the company won’t provide unauthorized services that most likely will be uncollectible. A correct patient profile at the start of care sets the groundwork for the most efficient claim submission and collection process. Using online payment systems to collect known balances prior to the start of service significantly decreases the amount of uncollectible dollars at the end of care.

The automation of processes not only saves time, it reduces the chances of errors to allow for a steady stream of revenue and cash collections.

Healthcare revenue cycle can be challenging due to the length of time it may take to submit a claim for services provided. Many insurance providers require a significant amount of documentation to be completed before a claim can be submitted. In these instances, the provider must rely on the physician overseeing the care to complete and sign documentation. Since the remainder of the patient balance is contingent on the final claim submission, the lag in billing makes it difficult to collect a patient balance for a service that was provided long ago. Technology can play a key role in this process.  By selecting a robust EMR that allows an agency to properly setup billing holds, eligible claims can be easily identified and sent out immediately when ready. Partnering with a vendor that assists with electronic document management is also essential in reducing the time it takes to receive these required documents.   Creating this streamlined workflow to receive incoming documentation allows for a quicker review and attach process. From optical character recognition to utilizing a barcoding system, each document can be uniquely identified and attached to the correct patient record with a simple touch of a button. The time savings this creates from both a workload and claim submission perspective is vital.

Typewritten claims, paper billing, and mailing documents are something of the past.  To maintain the optimal level of success, companies now utilize clearinghouses to submit claims electronically. A clearinghouse allows an agency to monitor the life of the claim from submission to payment. Receiving an automatic alert for a problem claim has now replaced the need for manual inquiries on payment status.  This allows an agency to redistribute their resources from claim follow-up to claim submission.  Denial management services are also key to success in an industry of varying payor requirements. These systems allow visibility into denied claims and suggestions on how to properly appeal the denial.  Not only does this automation save time, but it also increases cash flow and collectability. To further complicate the billing process, many payors have different timely filing limits, so it is essential to automate submission reminders based on timely filing. This automation allows the billing team to prioritize time sensitive payors to ensure claims are sent before the deadline has passed. Without technology, it would be impossible to keep track of these different protocols and securing payment for services would be even more challenging.

Reporting and monitoring key performance indicators are an essential part of maintaining the integrity of the entire revenue cycle system. Many EMRS offer automated reporting that can be measured monthly to determine opportunities for improvement.  These reports highlight anything from days to collect A/R, problem payors, and operational deficiencies that lead to collection issues. Investing in an EMR which presents these metrics at a glance allows an agency to proactively fix an issue before it becomes a financial loss. Agencies should continuously review the services offerings of vendor partnerships to ensure they are keeping up with the latest advances to address changes in the fast-paced health industry.

There is no doubt that technology has transformed the world of revenue cycle. Technology is no longer a choice within the health care industry; it’s a requirement. The automation of processes not only saves time, it reduces the chances of errors to allow for a steady stream of revenue and cash collections. Shorten the revenue cycle, decrease costs and increase revenue by transforming your revenue cycle through technology.

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As healthcare continues to transform into a consumer-driven marketplace, it’s incumbent on every employee of every provider organization to understand how they can positively impact the patient experience at their facility. We have marketing teams dedicated to attracting patients to the health system. Once they’re here, we have clinicians who take tremendous pride in providing the best health care to improve patients’ lives. So when it comes time for the patient to interact with the revenue cycle, why should it be any different?

At Cooper University Health Care, our focus is creating a best-in-class patient experience by leveraging technology in a way that allows our employees to focus more on the patient and less on the trivial headaches that historically come with revenue cycle work. Over the past twenty-odd years, technology in the revenue cycle has transformed a notoriously labor-intensive line of business into one that is much more automated. Perhaps the changes are moving too fast for many of us to keep a handle on. If you have ever been through a revenue cycle system conversion or implementation, you know that automating age-old manual processes creates challenges that make you question whether you know your own name at times.

As an industry, we’ve come a long way. We can now automate insurance eligibility. Patients can schedule their own appointments and pay their bills online. Medical records can be shared across multiple health systems to avoid mistakes and delays in care. We can code simple visits with computers alone. We can predict denied claims before they ever get adjudicated. The vast majority of our transactions with payers are now electronic. We can receive massive electronic remits, reconcile, and post them without even the click of a button. All of this has put our industry in a position to transform the way we think about the revenue cycle and its role in patient satisfaction.

At Cooper University Health Care, we implemented a new revenue cycle platform to integrate with our EHR in 2016. Over the past three years, we’ve experienced all of the benefits (and stress) that come with implementing these technological advances. Three years later, we have a stronger cash position, cleaner claims, and a more efficient business processing system. Through the pursuit of operational excellence in our business practices, we have been able to turn our attention where it should be: the Patient.

Not surprisingly, patient complaints to our billing office have reduced nearly 50% year-over-year.

As leaders in any healthcare organization, I believe it is our top priority to make our employees’ work as efficient, effective, and enjoyable as we can. By pursuing technology that will enhance employee engagement and satisfaction, we believe that it ultimately leads to a better experience for our patients. By engaging our employees in the design process of technology, you can mitigate their fear in what efficiency and automation will mean to them. Employees get to see what having more time allows them to do, and how it impacts the lives of real people each and every day. We take great pride in finding ways to impact patient satisfaction in each area of our Revenue Cycle.

Here are some of the ways that technological advances will allow us to focus on customer service:

In Healthcare Access, streamlining eligibility allows our team to spend less time on the payer portals and allows them more time the phone with our patients. Triangulating this data with contract management and CPT-driven orders will allow us to automate patient estimates. Our Financial Navigation Team is working to contact every patient before their scheduled procedure and explain their out-of-pocket cost and answer any questions they may have about their benefits or payment options.  This allows patients to make informed decisions and to avoid the “sticker shock” bills after they receive their care. Not surprisingly, patient complaints to our billing office have reduced nearly 50% year-over-year.

In Transitional Care Navigation (Social Work/Case Mgmt.), our teams have worked with our IT partners to implement real-time avoidable day tracking within the EHR. This allows our Transitional Care professionals to strategically drive improvements in length-of-stay, resulting in more efficient patient throughput and reduced delays in discharge.

In Health Information Management (HIM), we are implementing A.I. technology that will help us to prioritize charts for Clinical Documentation Improvement, Coding Quality, and Accuracy. This will ensure that the patient’s care is captured and documented completely with the patient’s insurance company, ultimately avoiding unnecessary denials. Many times, disagreements in coding can lead to denials or unexpected claim adjudication behavior which can affect the patient’s bill.

In our Business Office, our systems are working to identify incorrect patient balances, incorrect denials, and comply with regulatory requirements much more seamlessly than ever before. When processing over a million claims each year, being able to highlight the exceptions and work them timely has allowed us to actively handle what would have been a dissatisfying situation for our patients.

Seems simple, right? Well-deployed technology creates happy employees, which results in satisfied patients. It is simple, until the technology or the names on the badges change. If you want to deliver a consistent patient experience, you must deliver consistent training and education to your team.  That is why, at Cooper, we have created a Revenue Cycle Training and Education department.  This group is focused on hard-wiring the progress we’ve made operationally so that our teams can continue to focus on service to our patients. With the ever-changing landscape of payer rules, government regulations, and system upgrades, training and education is the grease that keeps the wheel turning.

Pursue operational excellence, install technology smartly to let your people shine, and hardwire the process with training and education. Your patients will see the difference. After all, isn’t that why we’re all here in the first place?

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