Ambient documentation with Epic helps reduce clinician burnout at Monument Health

The goal of its Nuance deployment is to significantly reduce after-hours “pajama time” charting while introducing the voice of the patient to the EHR, says its CIO and CMIO.
By Bill Siwicki
12:38 PM
Rapid City South Dakota Monument Health, which uses ambient voice technology for Epic EHR

Rapid City, South Dakota-based Monument Health

Physician burnout has plagued healthcare provider organizations for years, and COVID-19 has only made the problem that much worse.

Because of the surge of patients caused by the public health emergency, there is an even greater need to mitigate what the World Medical Association is calling a “pandemic of physician burnout,” with more than half (51%) of physicians reporting frequent or constant feelings of burnout. They cite administrative work as a key reason, according to the association.


Rapid City, South Dakota-based Monument Health, located in one of the current hotspots of the COVID-19 crisis, wants its physicians to be focused on caring for and engaging with patients, not typing up notes in the EHR.


The organization had been using technology from voice IT vendor Nuance for years to combat burnout and increase workflow efficiencies.

At the first peak of the pandemic, when telehealth was on the rise and Monument physicians were more pressed for time than ever before, Nuance debuted a new product called Dragon Ambient eXperience, or DAX. Monument staff believed DAX would make a natural and necessary addition to their existing suite of Nuance solutions.

“As telehealth has expanded during the pandemic, it has provided new opportunities for our patients in a remote geography, like South Dakota, to receive care without the complexities of travel and increased exposure, but it has the potential of further complicating the workflow for providers, as well,” said Dr. Stephanie Lahr, CMIO and CIO at Monument Health.

“The opportunity for DAX to be leveraged in a telehealth visit is so timely and eliminates the complexity of managing technology during a telehealth visit,” she said.

"All organizations are looking for ways to engage the patient, and adopting ambient documentation is the first step to not only engaging but also improving upon their experience."

Dr. Stephanie Lahr, Monument Health

To prepare for the surge in COVID cases, Lahr and her team figured out how to create new models for ambulatory care by standing up telehealth from concept to live in just three days. As virtual visits began to grow exponentially, she needed a way to support the growth in volume and create efficiencies.

“Nuance has long been a partner of ours, particularly in helping me to unify and optimize my Epic EHR,” she explained. “Also, our physicians use Nuance Dragon Medical One to document in the EHR via voice. So when the Nuance account team approached me about introducing ambient clinical intelligence into the documentation workflow, I was all for it. DAX securely and automatically captures and documents patient visits – in person and virtually – and onboards physicians quickly, easily and remotely.”

The initial DAX proposal included starting with a smartphone with multiple applications to capture multi-person/patient-to-physician conversations and then evolving that to include a wall-mounted ambient sensing device, which captures higher-fidelity audio streams collected from multi-person conversations.

Lahr and her team are focusing the first wave of DAX on a number of physician champions in neurology, primary care, cardiology, orthopedics and other surgical specialties.


There are a great many voice-recognition-technology vendors on the market today, such as Braina, eCareNotes Speech Recognition, Go Transcribe, iSpeech Translator, M*Modal Fluency for Transcription, NextGen Mobile Solutions, Nuance, SpeechLogger, Speechmatics, SpeechTexter, VoiceboxMD, Voicepoint Dragon Medical Practice and Winscribe Speech Recognition. Some vendors focus on healthcare, while others are more general, but can be used in clinical settings.


The ambient technology has restored the vital human element in healthcare and will enable physicians to get back to doing what they trained for and love, Lahr said. She expects to see an immediate reduction in physician workloads and a seamless transition to telehealth visits.

DAX is integrated within Monument’s Epic EHR platform and EHR services, including MyChart support and Clinical Service Desk, as well as with other Nuance Dragon virtual assistant technologies, Dragon Medical One, PowerMic Mobile, PowerScribe 360, PowerShare and Surgical CAPD. It also can support other third-party applications, like Microsoft Teams.

“The suite of technologies we use now securely and unobtrusively captures the details and context of physician visits with patients, in person and digitally, without interrupting the flow of natural conversation,” Lahr said.


Monument Health is in the process of rolling out DAX to 33 medical specialties, ambulatory centers and clinics. Once DAX is fully implemented, one of the key metrics Lahr and her team will be tracking is how much time has been reduced documenting in the Epic EHR after hours.

“Reducing the amount of documentation during ‘pajama time’ is among the key metrics we’ll be using to track success,” she noted. “That will tell me how much time is saved for physicians during the day. Equipping the physician to operate more efficiently and without administrative burden has and will always be my biggest priority in my dual role as CMIO and CIO.”


“Now that most organizations like Monument Health have rapidly stood up telehealth in a matter of weeks to months, the next step is to optimize and integrate telehealth solutions horizontally across the organization and change workflows,” Lahr advised. “Ambient technologies to document via conversational AI fundamentally changes the documentation workflow, making it more seamless and of a higher quality.”

This not only reduces provider burnout, but is the first step to engaging the patient in his or her own healthcare as the patient voice is front-and-center in the documentation process, she added.

“Right now, all organizations are looking for ways to engage the patient, and adopting ambient documentation is the first step to not only engaging, but also improving upon their experience,” she concluded.

Twitter: @SiwickiHealthIT
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