Nuance DAX

So today we’re chatting about Nuance DAX 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 a pediatrician who is part of a medical group in a multi-state hospital system. I see patients in both clinic and hospital settings. Additionally, I do some work in informatics.

You were originally using Nuance Dragon. Why did your health system look into and start piloting DAX?

Physician burnout is a significant issue, largely driven by the documentation burden. Our medical group leadership has been exploring options to alleviate this for the last six years. Between 2018 and 2020, we implemented in-person scribes, which helped reduce the workload. However, there were drawbacks, such as patient privacy concerns and the high turnover rate due to the nature of scribe positions. In my personal experience, a technology solution like Dragon PowerMic outperformed my in-person scribe in terms of spelling and medical terminology.

In March 2020, we discontinued the use of in-person scribes, and we’ve been navigating the post-COVID landscape with a focus on retaining doctors and reducing their documentation workload. Implementing effective solutions to this problem has become a major initiative to keep our physicians content and address their workload challenges.

How was the onboarding process to join the pilot program?

The pilot began with webinars that introduced the program and recruited participants. The onboarding process was straightforward, which speaks to the program’s customizability. I filled out an extensive questionnaire detailing my documentation preferences, including smart phrases, smart text, macros, and how I was using Note Writer. The team also reviewed my clinical notes from the previous few months to understand my documentation style. After completing a one-hour live training, my company provided me with an iPhone equipped with the application, and I started using it. Initially, I used the application for five patients daily over three days. Following a review meeting where I confirmed everything was satisfactory, I was authorized to use the application for all my patients. A few brief follow-up calls were conducted to check in.

Once you went into production, do you feel like they were able to take into account your preferences and the data they collected on you?

The initial setup required significant input, but it’s designed to adapt over time to my changing preferences. My practice focuses on well-child checks, which require a specific type of documentation. Impressively, the solution was able to integrate my note templates effectively. The process hasn’t been without its challenges—I’ve been providing almost constant feedback. The quality documentation scribes (QDSs), who seem to be based overseas, occasionally have issues with grammar, spelling, and accurately capturing what’s said. I’ve worked continuously with our representative to refine my templates and workflow to make it clearer for the scribes. For instance, I’ve shifted from using bullet points to paragraph format in my documentation requests, which they’ve adapted to well.

We were informed that after 1,500 patient encounters the system would run more smoothly, and that estimate seems accurate. Initially, there were frequent adjustments, but with six pediatricians in my practice now using the same templates and providing consistent feedback, there’s been a noticeable improvement in efficiency. The onboarding process has also become more streamlined, as new users can simply adopt the workflows that have been effective for me. While it’s not yet perfect and continues to evolve, having a team that’s responsive and willing to refine their processes has been helpful.

Can you describe how you’re using the product?

I use DAX for well-child and acute care visits. For acute visits, the process is streamlined because everyone in our system uses a specified template, aligning with the subjective, objective, assessment, and plan (SOAP) structure. For well-child checks, which require various screening tests and differ for each age group, it has been a bit more complex to integrate.

In telemedicine, DAX really shines. I explain to my patients that I’m using a virtual scribe and then position the device to capture the visit’s audio. This allows me to focus on the patient rather than typing notes. I can look up medical information during the consultation and also refer to resources, significantly enhancing patient engagement.

What’s transformative about DAX is the reduction in charting time. Before DAX, trying to engage with patients while typing was challenging. Now, I can fully face them, ask questions, and process the interaction without the distraction of documenting. I start recording as soon as I enter the room, capturing every part of the visit, including small talk as I’m getting logged in or washing my hands as well as the actual examinations.

This has lifted the cognitive burden tremendously. I don’t have to retain every detail, since DAX captures everything, allowing me to focus on the quality of care in the moment. This has changed the way I practice, making it more akin to past times when patient interactions were more personal. It’s also practical, as I’m able to manage seeing 80 patients a week without needing to spend hours on charting over the weekend, which has positively impacted the quality of my notes.

Are there any features that stand out as being particularly good or areas of constructive feedback for Nuance DAX?

The AI note-taking technology I observed is impressive. It’s capable of organizing notes appropriately, even when the conversation isn’t linear. However, concerns about accuracy remain, sometimes exactly the opposite of what was discussed. This can be challenging, given the complexity of medical dialogues and my style of pediatric communication, which isn’t always formally medical, such as when talking with an 11-year-old. The developers are receptive to feedback and proactive in addressing errors. They’ve engaged directly with me and my team to identify and rectify issues, and they’ve implemented additional checks when necessary. Overall, they seem to be quite adaptable.

How would you characterize the ease of use?

The device is very good, allowing me to view my schedule, see patient arrival, easily record, and flag urgent notes for prioritization. Additionally, I can delete recordings if necessary. Ad hoc recording is also a feature I appreciate; I can record with just a name and birth date if a patient’s appointment hasn’t fully registered in the system. Integration with my EHR is seamless, and it’s non-intrusive. It makes note of the scribe as part of the DAX system at the end of the documentation. That’s all pretty useful.

How does DAX get the notes back to you?

The final note is automatically incorporated into my documentation, and that can take up to four hours. They also shut down at 5:30 p.m. every day, and from Friday evening, they don’t resume until Monday morning. For providers who see patients on weekends, this delay is problematic, especially in urgent cases where a child seen on Saturday could be in the emergency department by Sunday. As a result, some providers have resorted to writing their own notes on weekends.

How is the overall stability? Have you encountered any bugs?

I’ve experienced occasional connectivity issues or problems, but the support team has been prompt in resolving them. They have a useful feature where it records and saves information even when offline and then uploads it once a connection is reestablished. There have been instances of server downtime, leading to delays in processing, but these haven’t been significant. Generally, it functions as expected.

How is the quality of the integration between Nuance DAX and Epic?

It seems a bit unsophisticated, particularly concerning the editing interface that lacks basic tools like spellcheck and grammar check. However, I’m looking forward to the significant enhancements we’ll get with the introduction of DAX Copilot. This addition is expected to automate all note-taking, eliminate the time delay associated with the human component, and reduce costs, since there won’t be a person in the workflow.

Additionally, the upcoming Hey Epic! will allow us to use voice commands for showing reports and placing orders, potentially revolutionizing the workflow. I believe we’ll be starting to use both DAX Copilot and Hey Epic! in the next few months. Currently, I use the Haiku app on my phone, but I look forward to a future where all of my devices integrate seamlessly with Epic. The goal is to focus more on practicing medicine and have the administrative tasks running efficiently in the background.

How would you characterize the support you get from Nuance DAX?

The company is very responsive and quick to address technical errors, which is a positive aspect. However, the quality of documentation was initially disappointing. Despite providing feedback on the necessity for proper grammar and professionalism in documentation, considering it is a legal document, there were ongoing issues. The company did acknowledge the need for improvements, but the problems persisted over months. They still have teams of people reviewing our notes, so they are actively working on it. Overall, there are mixed feelings; the responsiveness is commendable, but the challenges in maintaining professional documentation standards still leave room for improvement.

Looking back, do you feel like your health system made the right decision in going with Nuance DAX?

I’m confident that it was the right choice both for immediate and future needs. In the short term, it’s been so useful that we’ve had providers tell us they would consider leaving if we discontinued its use. Looking ahead even just six months, I see it continuing to evolve as an even better solution for us.

Do you have advice for providers who will be working with Nuance DAX?

I see a few common concerns among doctors considering DAX. One is during bilingual visits with an interpreter. DAX doesn’t understand the second language. If a visit is conducted in Spanish, for example, I have found that DAX will record the English parts, and after the visit I can complete the record by summarizing what was discussed in Spanish.

As I’m a pediatrician, I often see siblings during the same visit. DAX cannot distinguish between multiple patients. My approach is to focus on one sibling at a time, complete their visit documentation, and then proceed to the next.

Regarding patient consent for DAX, the patient can agree or disagree to have the audio recorded. If they don’t want the device in the room recording the conversation, I leave the room to dictate my findings so DAX can create the note. However, less than 1% of my patients ultimately refuse the recording. Some patients may be unsure or cautious about the process, but once I explain the benefits, including improved interaction during visits, most are willing to proceed.