Evaluating AI Scribe Solutions’ Core Functionality

Key Considerations for Evaluating AI Scribe Solutions Core Features & Functionality

Note Quality

• Note Structure: Ensure the AI scribe offers templates that align with the specific clinical specialty and can be easily modified to suit organizational and provider preference.

• Note Content: Evaluate the writing quality, ensuring it captures essential details relevant to the specialty and meets or exceeds the quality achieved by clinicians. Look for the flexibility and support for organization specific customization.

• Accuracy: Investigate how the vendor measures and validates the accuracy of their solution. Look for evidence of performance through case studies or data.

Integration with EHR Systems

• Assess the level of integration with existing Electronic Health Record (EHR) systems. The AI scribe should be able to seamlessly pull and push data, enhancing workflow without interrupting established processes. Evaluate:

• Whether documentation lands in the appropriate places in the EHR, including structured data fields and flowsheets

• Does it pull prior notes forward for your review

Multiple Recording Integration

Assess how the system handles multiple audio files, such as the primary visit recording, additional dictation by the clinician (pre or post), the medical assistant’s rooming note, and the possible recording of a physician’s assistant or other involved clinician, and evaluate how effectively the system integrates these into one comprehensive, seamless note. 

Support for Different Visit Types

Ensure that the AI scribe can document various types of visits, including new patient assessments, procedures, follow-up appointments, and annual wellness exams.

Support for Different Practice Settings

If you are in an integrated practice setting, you will want to investigate whether the solution supports different clinical roles, like behavioral health, optometry, or dental, and whether these other clinical practice setting visit types have appropriate note structure, content, and EHR integration to support effective use in varied practice settings. 

You should evaluate the pros & cons of single-sourcing one scribe solution versus using different scribe solutions that are practice setting specific. 

Performance In Suboptimal Circumstances

• Background noise filtering: Determine how effectively the AI scribe can distinguish relevant clinical conversation from ambient sounds like medical equipment beeps, hallway conversations, or HVAC systems that could compromise transcription quality.

• Multiple speakers: Assess the AI's ability to accurately attribute statements to the correct speakers when multiple healthcare providers, patients, and family members participate in the clinical encounter simultaneously.

• Multi-language support: Evaluate how the AI handles encounters where patients or providers switch between languages or require translation services, ensuring critical clinical information isn't lost across language barriers.

• Non-clinical conversations: Gauge the system's capacity to differentiate between medically relevant information and casual conversation, focusing documentation on content pertinent to billing and coding requirements.

• Varied accents: Measure the AI's proficiency in accurately transcribing and coding information from providers and patients with diverse regional or international accents that might otherwise lead to documentation errors.

• Glitches in the technology: Analyze how the AI scribe recovers from technical interruptions like connectivity issues or system lags, ensuring documentation continuity without missing billable diagnostic or procedural details.

Human-in-the-Loop (HIL) Involvement

Determine whether the solution offers a human verification option before finalizing clinical notes.

Mentero.AI always recommends a workflow that necessitates a HIL to ensure the note is accurate and complete. This minimizes risk to the provider, patient, and organization.

Revenue Cycle Support

When selecting an ambient AI scribe solution, thoroughly evaluate its medical billing and coding capabilities. The ideal system should:

• Automatically extract and suggest appropriate ICD-10 and CPT codes directly from natural provider-patient conversations without requiring manual code entry

• Demonstrate high accuracy rates (request vendor validation data) for code assignment across various specialties and complexity levels

• Provide real-time coding suggestions during or immediately following the encounter to streamline workflow

• Allow providers to easily review, modify, or approve suggested codes before final documentation submission

• Integrate seamlessly with your existing EHR and billing systems to eliminate duplicate work

Advanced Clinical Documentation Improvement (CDI)

Look for solutions offering sophisticated CDI functionality that goes beyond basic transcription:

• Intelligent analysis that identifies potential documentation gaps related to medical necessity or specificity requirements

• Automated prompts that suggest additional documentation elements needed to support selected codes

• Built-in compliance checks that flag potential disconnects between the narrative documentation and assigned codes

• Quality metric alignment that ensures documentation supports value-based care requirements and quality reporting

• Real-time feedback mechanisms that help clinicians develop better documentation habits over time

Mentero.AI considers both revenue cycle & CDI support core necessities because it helps deliver improved revenue capture and delivers a higher return on investment in an AI scribe solution.

Documentation Completeness and Compliance

Ensure the system produces comprehensive documentation that:

• Automatically includes all required elements for different encounter types (E/M, procedures, etc.)

• Structures information in compliance with payer-specific requirements

• Maintains audit-readiness by clearly linking clinical decisions to supporting documentation

• Provides customizable templates that align with specialty-specific documentation standards

• Generates documentation that meets both clinical utility and reimbursement requirements

Advanced Functionality in 2025 Ambient AI Scribes

As ambient AI scribe solutions continue to evolve beyond basic transcription, carefully assess these increasingly standard advanced capabilities that can significantly impact provider efficiency and patient care:

Clinical Decision Support Integration

Look for systems that intelligently:

• Analyze patient-provider conversations to identify clinical decision points and automatically suggest evidence-based guidelines relevant to the specific patient case

• Present contextual alerts for potential medication interactions, allergies, or condition-specific protocols without disrupting the natural flow of the encounter

• Offer risk stratification tools that highlight patients who may benefit from additional screening or preventive measures based on the documented conversation

• Integrate with your existing clinical decision support systems while adding conversational context that traditional systems might miss

Diagnostic Testing Automation

• Evaluate the scribe's ability to:

• Recognize verbal orders for labs and imaging studies during the natural conversation and translate them into properly formatted electronic orders

• Apply appropriate clinical context to ensure ordered tests meet medical necessity requirements

• Include relevant diagnostic codes and clinical indications to support insurance coverage

• Provide an intuitive verification interface that allows providers to quickly review and approve suggested orders before submission

• Track pending and completed diagnostic tests to support comprehensive follow-up

Specialist Referral Management

• Assess how effectively the system can:

• Capture referral intentions expressed during the patient encounter and convert them into structured referral orders

• Auto-populate referral forms with relevant clinical information extracted from the current and previous encounters

• Suggest appropriate specialists based on insurance networks, location preferences, and clinical needs

• Facilitate closed-loop referral tracking to ensure continuity of care

• Generate patient instructions regarding the referral process

Prior Authorization Automation

Prioritize solutions that:

• Automatically identify services requiring prior authorization and initiate the request process

• Extract and compile the clinical documentation elements necessary to support medical necessity

• Pre-populate authorization forms with appropriate clinical justifications derived from the encounter

• Track authorization status and alert providers about pending or denied authorizations

• Maintain an audit trail of authorization activities for compliance purposes

Medication Management Enhancement

Select systems capable of:

• Recognizing verbal medication refill discussions and generating appropriate refill orders

• Applying clinical safety checks before suggesting refills (appropriate intervals, contraindications)

• Managing controlled substance prescriptions in compliance with regulatory requirements

• Documenting patient-reported medication adherence and side effects to inform prescribing decisions

• Integrating with pharmacy systems to streamline the refill process

Final Thoughts

When evaluating solutions, it’s important to recognize that AI scribe solutions are always advancing their core features and technology. You want to find solutions that work well in your practice setting, are within your budget requirements, and have high-levels of accuracy, and integration. The price point between solutions without integration and with integration is negligible when you weigh the benefits of full integration.

If you need help in solution evaluation, Mentero.AI is here to help. Reach out to us at contact@mentero.ai today.

Look for our next post in this series: Technical Considerations