Custom-Built Documentation: Richmond Hospital Oncologist Refines AI Instructions for Detailed HPI and Investigationsx
Richmond Hospital
Richmond, BC, Canada
Doctor
Dr. Jeremy Ho
Specialty
Oncology
The system automatically format[s] the dictated content according to the template structure. Even if dictation is started after recording some conversation, the system will still maintain the template format for the entire note.
The challenge
Before Empathia
- Structuring Dictated Notes: Dr. Ho prefers to dictate, but manually transferring and formatting a dictated summary into the precise sections and structure required for an Oncology template (especially for investigations and lab results) was time-intensive.
- Inconsistent HPI Formatting: Maintaining consistency across multiple notes for narrative sections like the History of Present Illness (HPI) required repetitive editing, losing the benefit of dictation speed.
- Manual Customization of Patient Materials: The process of creating and customizing patient handouts for non-English speakers or specific forms was not streamlined, adding administrative load.
Dr. Jeremy Ho is an Oncologist at Richmond Hospital whose clinical workflow prioritizes meticulous detail in patient assessment and clear communication of complex data. His main pain point is the time-consuming process of documenting patient assessments and conversations, requiring both a thorough narrative (HPI) and highly structured data presentation (lab results, investigations). Dr. Ho, who has a preference for dictation for most of the encounter, required an AI solution that could not only capture his spoken words but also automatically format that dictation according to his customized oncology templates within the EMR system.
The Transformation
After Empathia
Key Improvements
Template-Driven Dictation
The primary workflow change involves using the Empathia dictation feature which generates structured notes based on templates. Dr. Ho can dictate the entire patient summary either before or after the visit, and the system automatically formats the content according to his template structure. This is a powerful fusion of his preferred input method (dictation) with his required output (structured note).
Layering AI Instructions
For high-stakes sections, Dr. Ho learned to guide the AI precisely:
- HPI: He now provides the AI with both content instructions and formatting preferences and plans to include examples from previous notes to ensure consistent style and tone.
- Investigations: The AI instructions are structured for elements like lab results and summaries to ensure highly structured formatting.
The Smart Edit Feature
He will use the Smart Edit feature for minor adjustments and training the AI, such as formatting the HPI in bullet points, allowing the system to learn from his specific style without needing complex initial instructions.
Targeted Feature Use
Dr. Ho plans to explore the patient handout template system for customizing and creating multilingual materials and noted interest in the form filling feature, which can automatically autofill PDF forms based on consultation notes.
Empathia AI successfully addressed Dr. Ho's need for highly structured documentation without forcing him to abandon his preference for dictation. The ability to use template-driven dictation and Smart Edit allows him to reduce the "documentation time tax" associated with transferring and formatting complex data. By customizing the AI instructions for the HPI and Investigations, Dr. Ho ensures that his high clinical standards for note quality are maintained automatically, leading to more consistent and clinically robust patient records at Richmond Hospital.
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Key Features Used
Smart Edit
AI-powered editing that understands medical context
Dictation
Voice-to-text with medical terminology recognition
Templates
Customizable templates for common visit types
