< + > Can You Build a Health Care System Without Notes?

Most transcription services and AI medical scribes aim to reproduce the SOAP note that has been the mainstay of patient visit records since the days of paper. Alex Butler, MD, Chief Product Officer at River Records, and his team started the company after reading a paper by Jake Kantrowitz, MD, PhD, Primary Care Physician & Chief Medical Officer, that led him to ask “Can you build a health care system without notes?” This video explains how River Records is working towards that vision.

Traditionally, a SOAP note documents a single visit. To see the trajectory of an illness—whether vital signs have improved or declined, what treatments worked and which didn’t, etc.—a clinician has to page through numerous notes or use some external tool to extract information. In today’s data age, information could be presented in a much more immediately useful, structured format.

River Records operates like other AI-driven ambient voice solutions, but produces a concise list of conditions, symptoms, and other relevant information. The tool is integrated with some 98 EHRs—Butler says it can work with any EHR used in the US or Canada—and they are working on deep integration with certain EHRs so that the tool can manage the problem list, check coding, and initiate billing. ICD codes are currently supported and CPT codes will be added.

Being able to pull information from the EHR, River Records can retrieve not only ancillary information such as lab reports and consultation documents, but information from previous visits. The result is a “problem-oriented document.”

The tool starts by identifying symptoms and conditions. It figures out what information in the transcript is relevant and sends that information as a set of instructions to pull information relevant to those problems from the transcript. The complete report is generated within seconds of the end of the visit. The doctor can also add their impressions before and after the visit to augment the information in the transcript. The tool asks them to review the report and add a summary framework

Doctors can attach the templates from their EHR so that information is presented in the order they like, combining many visits to create a “narrative.” Butler says the tool “opens up a ton of doors” for clinical decision support and other products. He finds that they work well for very narrow specialities as well.

Listen to the video for more information about how River Records adds terms to its AI model, checks for accuracy, and more.

Learn more about River Records: https://www.riverrecords.ai/

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