Background: Documentation burden has been on the rise since the introduction of electronic health records (EHRs). Artificial Intelligence (AI) scribes use ambient documentation technology with the potential to mitigate documentation burden. Few studies have investigated the implications of AI scribes on hospital medicine providers’ workflow and patient interactions. Methods: We conducted a stepped-wedge trial at [...]

Background: Accurate clinical documentation is essential for capturing patient severity of illness (SOI) and risk of mortality (ROM). These metrics directly influence hospital quality reporting, including rankings like Vizient and metrics such as Observed-to-Expected Mortality (O:E) ratios. Traditional documentation methods rely heavily on manual input, which in busy clinical practices, results in underrepresented patient risk [...]

Background: Risk adjustment indices are frequently used for hospital billing and reimbursements in the United States. Severity of illness (SOI) and risk of mortality (ROM) are two risk adjustment indices used in determining the APR-DRG, a classification system commonly used by insurers to determine hospital reimbursements. Recently, many health systems implemented AI-powered clinical documentation assistants [...]