Ambience Healthcare

So today we’re chatting about Ambience and how it’s used at your company. Before we jump into that, could you give a brief overview of the company and your role there?

I’m the chief medical officer for a primary care provider that focuses on patients aged 65 and older. My responsibilities include inspiring a vision for better health, building the care model, hiring, managing, and developing the clinicians, and informing the products, technology, and workflows that improve the experience for both patients and the clinical team.

What was the need that drove you to look for a solution like this?

I’ve been interested in these technologies for a long time, ever since I started using Dragon in medical school. I saw the potential for it to take things to the next level. Nuance’s DAX was something that caught my attention more recently during a vendor presentation. I was initially excited about it when we purchased it, but ultimately it doesn’t work well and my clinicians refused to use it. I had to hire human scribes in addition and ended up purchasing Ambience on top of our current DAX licenses. We won’t be renewing DAX when our contract ends early next year.

The reason we started looking into Ambience was because we were hiring human scribes for our care model. From a financial perspective, Ambience was a more affordable option compared to hiring human scribes, and it was also more reliable, since we were having difficulty finding and retaining scribes. The turnover rate for human scribes is quite high, so it has been an ongoing problem for us. We were trying to compare remote human scribing with the Ambience solution.

What were the requirements you used to evaluate Ambience and its competitors?

The main criteria for me were usability/clinician experience, cost, and quality. I also focused on the usability, measuring it based on whether it made my job easier or harder. Dragon, for example, ended up being slower for me to use because of the number of clicks involved to activate and deactivate it. DAX had a similar issue, as it was primarily focused on diagnoses and financial aspects, rather than the clinician experience. It could do diagnoses, but it didn’t write notes efficiently, leading to more time spent on editing than it was worth. From a cost perspective, I was looking for a solution that was more cost-effective than human scribes.

In terms of pricing, Ambience was in the middle range compared to other options like Abridge and Nabla. I looked into Abridge because it was cheaper, but the note quality wasn’t as good. Ambience stood out for two reasons. First, when it comes to writing medical notes, it does a great job with the assessment and plan section, which is crucial in value-based care. The grammar and language used make me look smarter compared to other products that don’t have polished language. Second, Ambience is almost magical in the way it generates patient summaries in patient-centric language. This is important because, although CMS requires us to write assessments and plans using medical jargon, we want our care plans to be patient-centered. Translating my notes into patient-friendly language is time-consuming, but Ambience does it automatically and beautifully.

How did Ambience compare to their competitors?

Ambience was the only one that showed me a real-time demo that produced a note on the spot. . I repeatedly say that if a company can’t do a live demo and produce a note, they’re probably not ready for prime time. Ambience was the only one that gave me a clinical note based on a five-minute pretend visit in real time. So, to me, it was the only one that worked.

As far as Nabla, I tested it out, but the note quality wasn’t as high, and I had to copy and paste everything. The thing about Ambience is that I just click a button and it puts it all in my EMR, since we’re using Elation. An unfair advantage for Ambience is that they worked with me to make sure it was the type of note I wanted, from a very person-centered approach. They understood that’s how it works in value-based care and what we needed to build. So I was able to work with them on building a better version. Nabla tried to sell to me several times; however, when I engaged they didn’t seem as enthusiastic about changing the product to meet our needs.

I loved Abridge because it started as a direct-to-consumer app from the patient side. I thought that was a brilliant method. The copy/paste feature wasn’t integrated, though, and the writing didn’t “make me look smart”, which is obviously an important metric. When it comes to clinician acceptance, how does it make the clinicians feel about their work? Does it make me feel like I’m doing better work than I could on my own? Or worse? The notes in Abridge weren’t as high on evidence-based clinical quality. They felt more like transcriptions from a Google Meet rather than a true summary with an assessment and plan. That’s also why I didn’t like Otter, because it felt more like a transcription than a good summarization with action items.

With DAX, it was more focused on the financial aspect and getting the diagnoses in, but it didn’t combine well with note taking. They may be better now, but as of this year, it didn’t work for me. As for Suki, it was over a year ago, and even then, they couldn’t show me the product and make it work. I would have had to download this, upload that, and pay them for this. So we didn’t get much further than that.

How did the pricing compare across the competitors?

Ambience was the perfect middle ground in terms of cost. It wasn’t the most expensive option, but it also wasn’t the cheapest. Since we were already paying for DAX and wanting the best, Ambience was a more affordable and effective solution. I did consider Nabla because it was cheaper, but it didn’t offer the same level of quality and integration. It’s been a while since I used Abridge, so I don’t remember if I ever explored the pricing. The notes themselves weren’t good enough for me to delve too much into it.

How was the sales process with the Ambience?

The sales process was interesting because, unlike the typical back-and-forth negotiation, they had a straightforward approach. As a doctor, I already knew the product worked and that clinicians loved it. Ambience basically said here’s the cost, take it or leave it. However, our head of sales wanted to negotiate, asking for a lower price and additional perks. But Ambience stuck to their guns. Yes, you can find cheaper options elsewhere, but they won’t be better. As someone who isn’t in sales, I liked the straightforwardness. However, the person leading the conversation on our side wanted to negotiate and felt like they were too rigid.

How was the onboarding and setup process?

I rolled it out for all our clinicians at the same time. We had a one-hour meeting where we installed the software on their computers. There were some hiccups during the first week, mostly related to remembering to turn it on and off. Either the software would run for a long time without the note popping up, and they couldn’t figure out why, or they would forget to turn it on when entering a room.

For new hires, we now schedule a 30-minute onboarding session. During this time, I set up their EMR and they work with the Ambience team to ensure it’s properly downloaded in the correct location with auto updates. The Ambience setup for clinicians is much easier than teaching them how to order labs, which speaks to the user-friendliness of the software.

I put in a lot of effort up front to make sure Ambience could generate notes the way I like. I’m a bit particular, but since I design care models professionally, I strive to improve any products I use. It’s a win-win situation, especially in the value-based care space. The software already worked well for fee-for-service, but there are differences in value-based care. So I worked closely with them to achieve a high level of quality for value-based care, rather than just focusing on saving time and increasing the number of visits. They do help with that, but it’s a different level of quality.

Interestingly, they said they’re able to use what they built for us for other specialties too. Once built, it worked well for different groups. In terms of setting expectations with my clinicians, I explain that this product writes “85% of their note.” This is way better than what we currently have available and made it so they didn’t get upset when they had to review and edit some of the content. Generally, Ambience would exceed the 85% mark; however, I find it better to exceed expectations for clinicians.

What use case do you use Ambience for?

Here’s how I generally use it. I start prepping the chart beforehand in my office, reviewing and mentioning things out loud, like their A1c and diabetes control. When I walk into the room, I turn on the laptop, if I haven’t already, and start my visit with the patient. The system listens to the whole conversation. At the end of the visit, I click on the “Formulate Note” button. It pulls up the note, and all I have to do is enter and verify the diagnoses.

Initially, I had to manually enter all the diagnoses because the auto code feature wasn’t available. Now, the auto code is really good. I tested it recently with a friend who pretended to have schizophrenia, and the system accurately pulled in the diagnosis without me even naming the diagnosis specifically – just based on the characteristics of the disease. The system has improved over time, and I no longer have to hunt down the ICD-10s. The note gets pushed straight into Elation with a single button click. In other places where I’ve used it, I had to copy and paste the note, but it’s still faster than typing or dictating the whole note because the quality is so high. This is what sets it apart from other products.

Initially I was skeptical, but it actually works great, and now I’ve rolled it out to all my clinicians. I love using it, and it’s frustrating when I have to practice elsewhere without it. I sound like a broken record, but it is truly the first technology product that has made my life easier, so I can’t stop trying to share it with others.

Where do you see areas of growth for Ambience?

One of the use cases they’re currently rolling out is how to review charts and provide insights without having to go through thousands of pages of electronic medical records. This is especially useful as we work with geriatrics who are generally very complex patients with multiple diagnoses. The goal is to serve up insights and gaps in care, such as Stars, HEDIS, and quality metrics and uncaptured diagnostic codes. These are important for value-based care and can impact revenue.

In my dream scenario, the technology could even automatically order tests based on what I say. Or it could prompt me on what tests to order based on the evidence or clinical pathways for various diseases.

As clinicians, once AI scribing technology becomes commonplace, it will change the way we interact with patients. It not only serves as a scribe but also allows me to focus on the patient and establish a connection without constantly staring at the computer screen. This redesigns the patient-clinician experience and introduces a paradigm shift.

What you lose with this shift though is the prompting that occurs within the visit while filling out the electronic chart. So we’re working on creating a clipboard-like view or an iPad interface that prompts clinicians with the necessary information on one page, rather than having to constantly look at the computer. This will enhance the patient-clinician experience. But for now, the technology works exceptionally well as a scribing tool that automatically writes my notes.

Is Ambience reliable?

The system is highly reliable. There was a one-hour downtime that caused distress for my clinicians because it usually works flawlessly. It was interesting to see how that short delay affected their perception. Thankfully, despite the issue, everything was recorded accurately and no patient visits were lost. However, they had to go back and complete their notes at the end of the day, which they now see as a burden, compared to their previous routine of writing all their notes at the end of the day.

I always make sure to remind my clinicians that, while this system is impressive, it won’t write a perfect note on its own. They still need to review and edit it. It will get your note about 85% of the way there, so it’s an incredible improvement from the baseline. However, if my clinicians anticipate the system to create the entire note flawlessly, allowing them to simply sign off and move on, they’ll be disappointed every time they have to make changes. So, just like with patients, I emphasize the importance of setting realistic expectations. If they expect the system to cure all their documentation challenges, they’ll be let down. But if it can help them improve their current situation, they’ll be satisfied.

Are there any weaknesses that you see with Ambience?

The main weakness was the lack of auto code, so the time it took for me to input the codes. However, they have addressed this issue, which is a sign of continuous improvement and responsiveness to customer feedback. So that was the biggest weakness overall.

Occasionally it generates information that may or may not be backed by evidence-based recommendations, information that the clinician isn’t expecting. For example, it might recommend a nutrition plan for individuals with coronary artery disease, even if the clinician didn’t explicitly mention it. This made them concerned that the system was fabricating information. Although it was designed to remind you to include important details in the after-visit summary, even if you forgot to mention them in person, this feature can be seen as a drawback rather than a feature.

How is the integration with the other tools you use?

Ambience’s APIs with Elation worked smoothly. I’m currently awaiting updates on the Epic rollouts, which I’m really excited about. Ambience already has some clients using Epic, and that could unlock so much of the market.

Do you have other team members besides physicians who are using Ambience?

We have other medical professionals, including medical assistants, health coaches, and nutritionists. We assessed the cost of implementing the technology for them. Currently, the value proposition seems too costly in terms of compute costs. However, I recently discussed the trade-offs with Ambience. They mentioned that if we can wait until the next day for notes, which is what most of these companies do anyway, it would be significantly cheaper. This approach would involve running the process during off-peak hours, similar to charging your car at night rather than during times of high demand. Although this adjustment would bring costs down, it is still too expensive for my non-provider staff to utilize right now.

How would you characterize the account management and support?

The account management has been amazing. We have a channel on Teams where our providers provide constructive feedback instead of just complaining. If they notice that a note didn’t appear, someone responds within a few hours with the reason, like forgetting to click a button or a short delay that will be resolved in 20 minutes, even though it’s usually faster than that. From an account management perspective, it’s better than any other product I’ve worked with. It’s been a fun experience. And we don’t have enough clinicians to earn special treatment, so it must be a standard practice.

Do you feel like you made the right decision in going with Ambience?

When it comes to the EMR, I find myself questioning my decision almost every week. However, choosing Ambience was one of the few decisions I have no doubts about. The only thing that made me question it was the possibility of finding a cheaper alternative, so I looked around, but no one else could offer what Ambience does. It’s always a priority for new startups to find the best and most cost-effective product. So, yeah, definitely the right choice.

Interestingly, I had one clinician who was exhausted and didn’t particularly enjoy the care model, but she said she was staying with our company because she knew she wouldn’t have access to Ambience if she went anywhere else. I cannot stress enough how much the clinicians appreciate it.

Do you have any advice for people who are trying to evaluate this type of vendor?

My advice to all my friends in the informatics field is simple: if a vendor can’t do a real-time visit and produce a note within a minute, they’re not ready for prime time. I haven’t come across anyone else who can listen to a five-minute conversation and write a great note. So when testing out these types of technology, don’t expect them to perform well in a busy, chaotic, real-life environment if they can’t do it flawlessly in a demo. In a real clinical practice, there are countless interruptions, the Wi-Fi goes up and down, and it’s generally a busy place. For example, we tested it in the cafeteria with loud music in the background, someone trying to take our plates, and numerous interruptions, and I had a friend who was constantly “paging me” throughout the whole process, being annoying, and it still produced a lovely note. So make sure to test it in with a mock visit and have one of your clinicians evaluate it. Most of the vendors claimed they could do it but didn’t give me anything in real time.