Voice-Based Conversational Interfaces Will Revolutionize EHRs and Enhance Patient Care

Q. Hi Yaa, welcome to the Big Unlock podcast. So, I’m Rohit Mahajan. I’m the CEO and managing partner at Big and Demo Consulting. And we’ve had the good fortune of having you on our podcast once before when Paddy was running it. So welcome back. And with that, would you like to introduce yourself to the audience?

Yaa: Absolutely. My name is Yaa Kumah-Crystal. I’m a paediatric endocrinologist and biomedical informaticist, and I serve as a clinical director of health IT at Vanderbilt University Medical Center here in Nashville, Tennessee.

Q. That’s awesome. Tell us a little bit more—how did you start in this field of being a physician, and what attracted you? How did you move from being a practicing physician into health IT, which is a dry field for many people?

Yaa: I think the luck of it all is that one of my features and bugs is that I’m a complainer. I’m always trying to improve systems around me, always finding opportunities. When I came to med school, we were transitioning from paper to the EHR, and as we started using some of the electronic health record systems, I had a bit of a computer science background. I saw that there were lots of ways we could be improving things—the way data flowed, to not have to repeat entry. I think I just complained, complained, complained to enough people that they said, “You should talk to Kevin Johnson.” He was the chair of our biomedical informatics department. He said, “You think you have some good ideas that can improve things?” And I said, “I think I do.” He was like, “You should consider informatics.” And through luck and happenstance, I got involved in a lot of really interesting projects in improving the EHR. Got my master’s in biomedical informatics and was able to get a position serving in health IT to improve the EHR.

Q. That’s awesome. So talk with us about some of these early experiments in improving EHR, because they’ve come a long way now—including, we were just talking about how Epic is integrating generative AI into the product itself and the platform itself. Share with us what you’ve seen so far, and where you think it’s going in terms of all these new developments.

Yaa: Sure thing. It’s funny—I almost want to break up the EHR into three eras: the paper era, the classic data entry era, and now the generative era In the classic era, there are a lot of great concepts and thinking to improve the way we’re. Capturing information because a lot of the problem was we had these paper records and people would just clone a paper form into a digital form and say, have at it. Go ahead and enter all this data in doctors, and please do a good job on the way and don’t miss anything and make sure you can get everything for our quality improvement and billing.” Doctors were getting so frustrated, and we tried different modalities to improve things. We had dictation, voice technology—we even worked on a project that was a voice assistant for the EHR, kind of like Alexa, early on. You could ask it things and get information back. We collaborated with Epic on a tool called “Hey Epic” to talk with the EHR, but architecturally, it was so complicated to plan for every single way someone might ask a question.

Then generative AI—large language models—entered the scene, and suddenly the concept of naturalistic interaction became feasible. You can now ask for things and get responses in the way we think about them as humans. Is just part of what we do now. So a huge aspect that has been an improvement that doctors have seen right away is ambiance workflows. So being able to just have a regular conversation with your patient, have the AI do all the work of the documenting for you. Yeah. And generally, note at the end so you can pay attention. So the person in front of you has been such a game changer. We literally get emails from providers saying, “This is such a game changer. I get my notes done on time. I can pay attention to my patients.” And it’s getting better every day.
So I think this new era, following the standard digital EHR era, is going to bring some of the most exciting advancements in patient care.

Q. Yeah, that’s good to know. One of the things you hit upon—ambient listening and integrating it into workflows—is resonating across the board. It’s quickly becoming a key technology that everyone is going to use. What others do you see on the horizon as you look around and evaluate developments in the generative AI space?

Yaa: What I see—and I’ve always been interested in—is voice technology and being able to converse with technology the way we’re conversing right now. I think everyone listening to this podcast has probably played with ChatGPT, Claude, and other similar tools. One interesting feature I find is voice mode, where you can ask questions and get responses back. Any of us who’ve played with, you know, the older Siri and all that stuff, know that. Sometimes you ask the question, it’s like, um, I’ll search the internet for you. And you’re like, ah, yeah. But with these tools now you ask it and you get something back, and the thing you get back is related in context to the thing you’re asking for, and you can ask follow up questions. My biggest question is when will we be able to integrate a workflow like That into the EHR, because many times when you are trying to put together the story of a patient to figure out what to do next or what’s been going on with them, you have the questions in your mind. You’re like, when did they last get this test? Or how many times have they, um, been to the hospital for this particular issue? These are questions you have in your mind. To find them, you have to navigate the EHR. You have to say, well, if I wanna figure out how many times they have an encounter, I need to go to the encounters tab and I need to filter for ED visits.

And there are these steps that you’re taking to answer this question, but what if you could just like ask the question and then have the EHR understand you because it’s , it has this transformer architecture in the background that. Understands that can inter interpolate what is you’re saying and feed you back the information, and that takes off so much of the cognitive burden of the work to find the things you need to care for your patient.

Q. That’s so interesting you say that because recently, I’ve been talking with several people—including at VIVE —and one of the leaders I speak with often, Dr. Ashish Atreja, described it as a “headless EMR EHR.” The voice interface comes to the front, allowing you to ask questions in natural language, while the EMR EHR itself fades into the background for the purpose of just gives you the answers. It’s fascinating that you’ve been following this for so long.  Let’s flip perspectives now—how does this look from the patient or caregiver perspective?  And we were chatting about patient portals a few minutes ago before we got on the podcast. How are your paediatric patients and their caregivers embracing this technology, and what are they asking for?

Yaa: This has been a very interesting time as a paediatric provider because our patients are young, and their parents are from an early tech-savvy generation. They’re more in tune with technology than, I think, some of the older patient populations in internal medicine, for example. I’ve actually had a patient say to me, Hey, I ran this through chat GPT, and this is what it told me. Do you agree? And what my relief was that they asked. Me for my opinion, yes, to see if I concurred with what chat GPT was giving them course, but I don’t think it’s gonna be a long time until we’re going to start seeing patients discover more and more that these tools are able to give responses. The only concern that I have is how reliable and accurate these responses are, and what responsibility do we have as a medical organization to work, to develop tools where that they can safely ask for questions and can give back more certified, approved answers  to answer some of their questions.

Concern that I have is how reliable and accurate these responses are, and what responsibility do we have as a medical organization to work, to develop tools where that they can safely ask for questions and can give back more certified, approved answers, uh, to answer some of their questions

Also, circling back to voice user interfaces on patient portals—patients are navigating these platforms trying to find information, but sometimes they just have a question. What would it look like if they could ask the portal: “When’s my next appointment with Dr. McChrystal?” or “Are my labs back yet?” or “Hey, I need a refill on my albuterol—can you send that in?” And then those things just happen as part of the process. Right now, the buzzword is “agents.” So we’re talking about smart agents that can make our patients’ lives easier.

Q. That’s awesome that to think that we are, because I would love to do that. Ask my a question and get an answer back instead of us trying to validate my, my user ID and password. 

Yaa:  And that’s the thing because um, there’s so many, there are really interesting ways to authenticate people like it would know your voice. There are other factors, like it knows that, oh, you’re nearby because it detects like your phone’s nearby. There are just. Many ways. It’s such a fun time to be a nerd right now because there’s so many things that are converging with a lot of technologies we’ve been thinking about for a long time. 

Q. That’s great. So that leads me to my next curious question: in a large system like yours, how do you approach innovation and new technologies? Do you measure return on investment? How do you decide your next projects for, say, this year or the next?

Yaa: Great question. Vanderbilt is a large academic organization. We have trainees and a lot of researchers. I think we’re all aware of the changes happening in the broader landscape around funding and priorities, so we have to be thoughtful about how we implement technology—making sure it serves our mission and benefits our providers. At the same time, we want to try new things and partner with vendors to say, “Hey, we’re experimenting with this, and we have opinions and suggestions for improvement. So I think part of our strategy is to do early pilots. So we can help to steer the direction that these tools are going to be materializing when they go to full production. At the same time, we aim to deeply understand what ROI even means in this context. Are we trying to improve turnaround time for notes? Reduce pyjama time for providers Do we want to decrease the number of messages that patients want to send back and forth? Once you can really define what is you’re trying to improve, then you can figure out how to measure it. And once you can measure it. Then you can really know if you’re making an impact. I think a common concern that people raise with looking at ROI is, well, sometimes the ROI is just that your providers are less miserable, that they’re less out, and how do you measure something like that?

There are interesting metrics that can help us assess whether the cognitive and emotional load on providers is being offset by the tools we provide. Some of these tools aren’t inexpensive, but I think we’ll start seeing providers expect a certain level of expectations that their EHR systems are working at a certain state of the art. EHR systems are working at a certain state of the art. I work with trainees and one of my trainees, she’s finishing up her training and she was looking for a new organization and she joked to me, she was like, well, I sure hope they have ambient there because I’m so spoil right now. I don’t know what I’d do without it.

Yeah, that was a joke that she made because it’s so early days, but I think it’s actually gonna become a truth where if your organization is not on the leading edge and not providing these tools to improve the way your providers work. People might decide that they want to go to a different organization. So, I think the people in the C-suite needs to be giving that consideration. 

Q. That’s great to know. So, you touched upon this, topic of one of your trainees. So, talk with us about education, training and learning initiatives in the community or at the. At the health system, how do you go about that? How do you level up and what are some of the things that you can do about it? 

Yaa:  Yeah, this is a really, really fascinating part. A lot of the new tools that we have help people become more proficient and help people be more efficient. You help you see patients faster, help you write notes faster, and that’s great. But on the other side of the coin. Trainees are not just supposed to learn how to be efficient. They’re supposed to learn how to practice medicine and how to balance logistics. So, we need to find a good balance of teaching them how to use the tools they’re gonna be using in the future, but not to the extent that we’re impeding on. Their actual learning process. In medical school, I took a course on how to write a good medical note because you had to think through the diagnosis. You had to figure out of all the things the patient told you, what things do you wanna keep in the note? What things do you leave out of it because it’d just be too much and that’s distracting. You have to do that synthesis and assimilation yourself. Well, we have tools to do that. Now, does that mean that we don’t teach students what a good note is anymore? Do they just solely rely on something that’s generated? These are decisions that we are going to be making and making in real time because no one knows the answer. cause we’re on the pioneering edge of it all.  But I think we need to not forget that trainees being a medical student, a resident, a fellow. It’s not just about learning how to be efficient. You need to reach a level of proficiency before you need to worry about efficiency. So, we need to make sure that we’re teaching them things they need to be good doctors so they can be efficient, good doctors eventually.

Q. Do you give that into your program over there? How does that? 

Yaa:  Absolutely. Yes. We have medical students and we all sorts of trainees that rotate through and I, I love, love working with trainees because they will ask me questions about things I have never thought about. I’m like. Let me go look that up. Yeah, just think of things in very, very new and interesting ways. 

Q. That’s very cool. So just curious that, you know, many times the focus is on the main system, which is the EMR EHR system. Let’s say a pick  Epic in this case, and then there’s patient portals. It could be MyChart or anything else from the same vendor or, or different providers as well. What other systems is a physician touching upon during their work? Which could be transformed digitally. Any thoughts on any other systems which come into play? 

Yaa:  So many, so many. So communication systems in general, a lot of what we do is communicating. Yeah. In the medical system, we’re still using like fax machines and pages. Yeah. Like we’re singly keeping those industries alive. There’s. So many ways, things could be improved about the way we communicate with other medical centers. Interoperability is a huge, huge challenge that we’ve been trying to tackle for years. Where I see a patient, they’ve been referred to me, their paediatrician has all their records and all their growth charts, and I’m like. Boy, I wish I had those. Yes, and they’ll fax me something and I can like pull up a very fuzzy PDF. I’m like, oh, there’s got to be a better way. And we know there is, we have standards like Smart on Fire where yeah, we were integrated appropriately. Everything that they had could magically show up on my growth chart, that so many opportunities there.

Q. I would like to ask you if there’s any other thoughts you have in closing, and if you were to look in the crystal wall, what you’d see, see coming our way in the next, let’s say, one to two years, and any other thoughts that you would like to share with the audience?

Yaa: I think my crystal ball is going to be really interested in how care can be delivered more at home and how we can get more insights from patients based on what they’re doing outside of the medical centre. So I’m a paediatrician, so I care a lot about kids and the fact that they spend most of their time just in school and the school nurse. That’s our main touch point to anything that’s going on with like our patient’s diabetes and what tools do we have that can help us. Better understand what’s going on with our patients when they’re outside of our medical center walls. So with diabetes, they have these things called continuous glucose monitors. That can help. Blood sugars are periodically. What are interesting ways for me to get the information in real time, to get alerts, to get, stratified risks of the patients that have the different technologies so I can know how to act. How useful would it be to have information like that available for. All sorts of patients for anyone on their watch, just so we can get a sense of which patients we need to make sure that we’re really engaging with so we can help improve their health and on the patient’s side, so they can have a sense of autonomy also, to say like, Hey, I really understand these details about my health. I’m getting these insights from my environment, and I can be proactive about how to stay well. 

Q: Great. So with that, yeah, I think thank you for the podcast being a guest on the podcast second time around like we, we talked about, and thank you for your time. 

Yaa: Thank you so much. I look forward to a third, fourth, and fifth time we’ll talk about Yeah, of course. What we got. Implement our, our new robot army to take care. We hope you enjoyed this podcast. 

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity.