Nabla

So today we’re chatting about Nabla 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 head of product for a concierge primary care practice that offers all-inclusive primary care and some specialty care services. Our members pay an annual fee that covers everything within our primary care umbrella. We have our own on-site labs, imaging, and pharmacy. We offer services for both adults and pediatrics, including cardiology and neurology consults, all of which are done in-house. We also provide services in-home. Our membership base consists primarily of couples and families.

What was the need that drove you to look for a product like Nabla?

When members join our practice, they go through a comprehensive health assessment that generates quite a lot of documentation. Providers struggle to generate and manage all this documentation and it takes up a significant amount of their time, which is why we decided to start testing tools like Nabla that purport to generate this sort of documentation automatically. Also, with the introduction of so many new AI tools in healthcare recently, providers started to proactively ask when would start using a tool like this.

What were some of the requirements you used to evaluate AI scribes?

As a cash-pay clinic, we didn’t prioritize coding or billing in our evaluation process. What matters more to us is the user experience for our internal users and the quality of the generated notes. Our visits are fairly comprehensive, sometimes lasting multiple hours, so we wanted a tool that could automatically capture all the information discussed during these visits. Price did matter, but it wasn’t the most important factor. We were willing to spend more for a better tool. The sales process was also a consideration - we wanted something that we could get in the hands of our physicians quickly. We also wanted a product that allowed our providers to have flexibility in their note-taking styles or templates. We have many different visit types, and different providers have different preferences, so configurability of the generated note was important to us.

Who were some of the other vendors that you looked at, and how did they stack up?

We’ve spoken to Ambience, Abridge, Suki, and Nuance’s DAX Copilot, each of which has posed different challenges. Abridge recently announced a partnership with Epic and, after that, it seemed that we couldn’t make progress with them since we use Athena. They also don’t offer a publicly available demo. Ambience evaluated us and declined to do a pilot with the rationale that they didn’t believe we could generate enough additional revenue per provider to meet their threshold for value. Given that a big part of their product focuses on value-based care and billing, it’s understandable they weren’t the right fit for us. We are currently evaluating Suki and have yet to go through the full process with Nuance’s DAX Copilot.

How do the different pricing models compare?

Nabla has a pricing table on their website (https://www.nabla.com/blog/ai-medical-scribes/) that breaks down their as well as other companies pricing models as of June 2023 - this was particularly useful for us because this information is not typically public. Nabla’s pricing is $119 per month per provider, which is pretty affordable. We did not receive pricing information from Abridge. Ambience, on the other hand, charges around $10,000 per provider per year. DAX Copilot is around $700 per provider per month with the pricing being broken down into $100 per month for Dragon Medical One, the dictation software, and $600 per month for the DAX Copilot add-on. Suki is priced at around $150 per provider per month, so pricing varries significantly.

How do you feel about Nabla’s sales process?

We reached out to Nabla to ask them how much it would cost to provide custom note templates. In response, they proposed a pilot project that would involve evaluating the tool’s efficacy and time-saving capabilities, quantifying the potential return on investment as well as provide a single custom note template. For context, Nabla currently offers set note types (e.g. General, Cardiology, SOAP), but those types didn’t meet all of our needs. In discussion with Nabla about this pilot and the cost of the custom note template, it became clear that Nabla is a fairly new company without mature professional services. Ultimately, this discussion raised concerns about the potential cost of creating additional note templates in the future. Instead of proceeding with the pilot, we ended up setting our providers with the standard note templates and it’s working reasonably well.

How was the onboarding and setup process?

Any reasonably tech-savvy person would find that it’s very easy to set up and get going. I give Nabla significant credit for being the only AI-generated note company (at least that I’m aware of) that offers a demo you can use without speaking to a sales person. This is a huge plus in my opinion.

How are you using Nabla in your workflow?

Initially, the intended use case for Nablawas to record clinic visits and generate notes, so I bought Bluetooth microphones to make it easier for providers. But our providers already had a workflow that they were comfortable with around documenting regular patient encounters. It turns out that they actually wanted to use Nabla for ad hoc phone calls with patients or other providers. In these cases, remembering to document was more challenging because there wasn’t an existing appointment or note to remind them to complete documentation. This is A particularly important use case for our company because we encourage our patients to contact their doctors directly with questions. So the primary use case of Nabla ended up being all the communication and patient care that happens outside of formal visit encounters.

What features do you like about Nabla?

One feature we really appreciated about Nabla is the transcript that’s generated alongside the note. Many AI note tools including DAX Copilot, Ambience, and Suki, do not provide a transcript directly to users. Having access to the transcript is valuable for us because it allows our providers to refer back to it if the generated note is missing important information. The transcript that Nabla provides may not be the best in terms of accuracy, and there doesn’t appear to be any post-processing to clean up errors, but it gets the job done and is available in real-time.

What do you see as some of Nabla’s strengths and weaknesses?

Nabla is an excellent tool for addressing routine medical issues and standard medical encounters. I imagine it works great for providers who see routine cases. However, where Nabla falls short is in capturing complex medical information and filtering in/out what it deems as extraneous conversation. For example, one of our providers was discussing ice baths and their benefits for reducing inflammation with a member, but Nabla determined that information to be irrelevant to the medical situation. While some may see this as a good filtering feature, the provider felt it should have been included.

One limitation of the Nabla web app (not specific to Nabla but worth mentioning) is that pn iPhones, only one application can access the microphone at a time. This meant that providers had to use the speakerphone function on their phone and use their laptop while on a call if they wanted to use Nabla. I believe this is a security feature from Apple’s perspective, but it was challenging for me to explain to providers who expected this to “just work”. Overall, while Nabla is not a be-all/end-all solution, it works well for most use cases in my opinion. Nabla is very much a jack of all trades, master of none.

One aspect of Nabla we are particularly impressed with is how quickly they roll out new features. We have a good relationship with their team, so they email us about beta features. One feature they recently rolled out is the ability to nudge the model. For example, if we write “Add additional detail to the physical exam section,” it might add additional detail to the generated note. This feature is quite a technical challenge from my perspective, so it’s impressive that they can roll out these features in weeks, not months. This gives me confidence in what they might offer in another six months.

Is the platform reliable and bug free?

There are always opportunities to improve the note and transcript quality, but the tool works, and it’s free for up to 30 consultations/notes per month. Hard to complain about that.

In terms of the UI and usability, how are providers interacting with the tool?

The UI is intuitive for providers. The biggest challenge for us is that Nabla doesn’t (and doesn’t seem to intend to) integrate with EHRs. They offer APIs for customization, but they don’t have a professional services arm to help with integration into specific EHRs. Nabla does breaks out structured sections of the note like HPI, review of systems, assessment, and plan, however, and provides a button to copy and paste those sections into the right place in the note. Some of our providers still struggle with this though and end up pasting the whole note into one section in Athena, which is not ideal.

On the UI side, Nabla claims to not store anything on their servers, allowing them to claim some degree of HIPAA compliance. They offer this as a feature; however, this means that if you close out of your session or log out, you lose access to all previously generated notes because they’re not stored on their side. This has caused some confusion and frustration for providers who don’t understand why they lost access to their information.

Have you used Nabla’s APIs?

No, we haven’t explored their APIs. It seems that they require an enterprise-level agreement for API acces. My impression is that while they do offer APIs, this is not the primary way they intend for users to use their product.

Have you integrated Nabla with any other products?

They have a Chrome extension that can be used with Athena. While I don’t consider it a true integration, my providers do. They appreciate that they can be in Athena, open the chart, click the Chrome extension, and record a consultation.

How do you feel about Nabla’s support?

They have been very responsive to us and have taken our feedback into consideration. They seem to actively engage with their users and seek feedback. I mentioned that I was evaluating their product for my providers, and they offered to provide access to their standard return on investment measures if I was interested. Overall, I have been impressed with their level of support. As someone who is comfortable with a variety of digital solutions, this is what I expect. It’s a very different experience compared to dealing with Nuance, where there is a clearly defined sales process and specific questions that need to be answered in order to receive a response. I’ve been really appreciative of Nabla’s level of support.

Do you feel like you made the correct decision in moving forward with Nabla?

This sector is evolving rapidly, and I’m glad that I’m not tied to an annual contract that would limit my ability to use new tools. Nabla is iterating quickly and may improve even further in the next few months. It’s a huge advantage that we could try the product without any upfront commitment. This is especially important because we’re currently evaluating Suki, which requires all of our providers to do a 45-minute Zoom call with their team. I believe that most of our providers won’t be willing to do that. The fact that Nabla can be used in its entirety after five minutes of set up meant that my providers were open to trying it and has sparked conversations about other possibilities in this space. With many companies, you never get past the salespeople, so I’m actually quite pleased with our experience with Nabla. If we had someone who was using Nabla extensively, we would absolutely be willing to pay for it.

What do you see as areas for growth for Nabla?

Continue to offer additional note templates. That’s big for us - it’s a real sticking point. Improve the transcript quality. Improve the note quality. I believe all of those things will happen, not just because of Nabla, but also because of improvements in generative AI in general.

Do you have any advice for people who are currently making decisions about this type of technology?

If you’re considering using a generative AI note solution at your practice, I recommend starting with Nabla. However, if you have specific requirements like automatically generated CPT or billing codes, or if you absolutely need direct integration with your EHR, Nabla may not be the right fit for you. My recommendation is to start with Nabla and then explore other options if necessary.