AI Scribes: Hidden Costs Behind Documentation Relief
The healthcare industry's rapid adoption of artificial intelligence-powered ambient scribes represents one of the most significant technological shifts in clinical documentation in recent years. While early studies demonstrate reduced documentation burden and increased clinician satisfaction, a new editorial in JAMA Health Forum raises critical questions about the broader implications of this technology for healthcare spending, quality of care, and health equity.
The Promise and the Investment Surge
Investment in AI ambient scribes has surged dramatically, with health systems across the United States piloting this technology at an unprecedented scale. In 2025 alone, AI scribe companies announced nearly $1 billion in funding, signaling massive industry confidence in the technology's potential. The value proposition appears straightforward: by capturing clinical conversations and automatically generating documentation, these tools promise to liberate physicians from the administrative burden that has long contributed to professional burnout.
Recent research supports this promise. Studies have found that ambient scribes meaningfully reduce time spent on electronic health record documentation. Clinician enthusiasm has been notable, with physicians reporting improved ability to maintain eye contact with patients and engage more fully in clinical encounters. One health system reported over 2.5 million uses of ambient AI scribes within a single year, demonstrating the technology's rapid integration into everyday clinical practice.
The Upcoding Concern
However, as Pragya Kakani, Austin Kilaru, and Melinda Buntin argue in their JAMA Health Forum editorial, the financial incentives underlying ambient scribe deployment warrant careful scrutiny. The authors note:
"Although not the only means to offer a financial return, there is a real risk that financial return will be generated through more intensive diagnostic coding."
This concern is grounded in well-documented healthcare economics. Prior research has convincingly demonstrated that health systems strategically upcode services when financially advantageous, contributing to escalating healthcare costs. The sophistication required for effective upcoding has historically limited its widespread adoption, but AI ambient scribes may fundamentally change this calculus by automating the process.
The mechanism is straightforward: ambient scribes capture more granular data from clinical encounters than physicians might otherwise document manually. The AI then optimizes this documentation to maximize the recorded complexity of patient encounters, potentially inflating the diagnostic codes submitted for reimbursement. This automated optimization could occur without explicit instruction or even awareness from treating physicians.
The editorial authors observe:
"Ambient scribes have the potential to automate upcoding by capturing more data than clinicians might otherwise record and then optimizing documentation to maximize the complexity of recorded patient encounters."
Beyond coding intensity, ambient scribes may also drive increased healthcare utilization by predicting additional care needs and prompting clinicians or patients to pursue additional services, regardless of clinical necessity.
Uncertain Financial Impact
Despite these concerns, the actual financial impact of ambient scribes remains uncertain and potentially multifaceted. Current evidence on return on investment for health systems is limited, with some reports suggesting minimal financial returns. This suggests that any increases in spending due to upcoding may be counterbalanced by reductions in administrative costs, including decreased time spent by physicians and administrators on billing and prior authorization processes.
Furthermore, healthcare payers are unlikely to remain passive observers. Insurance companies will likely deploy their own AI-powered tools to detect and respond to coding patterns suggestive of upcoding, potentially through claim denials, financial penalties, or network exclusion. This strategic response may mitigate cost escalation, though public payers like traditional Medicare may face disadvantages given their limited existing utilization management tools and potentially slower policy implementation timelines.
Quality of Care: Promise and Peril
The impact of ambient scribes on healthcare quality presents similarly complex considerations. Early evidence suggests potential benefits for patient experience, as clinicians can maintain focus on patients rather than documentation screens during encounters. However, evidence regarding actual patient outcomes remains notably limited.
The optimistic scenario envisions ambient scribes identifying opportunities for guideline-concordant care, recognizing needs for important screening tests, vaccinations, or recommended imaging. The editorial authors acknowledge:
"There is some optimism that the deployment of ambient scribes can identify opportunities to deliver guideline-concordant care, recognizing the need for important screening tests like vaccinations or recommended imaging."
Data collected by ambient scribes could prompt clinicians or patients to pursue high-value additional testing, potentially improving population health. Looking further ahead, ambient scribes may assist with diagnosis, providing suggestions for diagnostic testing and potentially reducing specialty referral needs or accelerating time to diagnosis.
However, substantive concerns exist regarding potential adverse effects on clinical practice quality. First, ambient scribes may paradoxically increase documentation volume in select cases, as manual editing of AI-generated notes can prove time-consuming. Excess information recorded represents a paradigm shift from the traditionally selective communication of clinical information.
Second, AI confabulations or misinterpretations of human communication pose real risks for documentation accuracy. Research on large language models has demonstrated concerning hallucination rates in medical text summarization, raising questions about clinical safety.
Third, overreliance on ambient scribe documentation may erode clinical accountability. As the editorial notes:
"Overreliance on ambient scribe documentation may erode clinical accountability, as clinicians may become too reliant on AI-enabled decision support or other prompts that result from ambient recordings."
These concerns do not warrant abandoning the technology but underscore the need for clinicians and health systems to anticipate and actively mitigate potential adverse effects.
Health Equity Implications
The equity implications of ambient scribes present perhaps the most complex considerations, with potential effects in multiple directions. On one hand, ambient scribes may reduce disparities in documentation quality across patient groups that result from clinician bias or limited language proficiency. Standardized AI processing could theoretically produce more consistent documentation regardless of patient demographics.
However, significant equity concerns remain. Current ambient scribe technology may not be optimized equally for all populations, particularly across different languages. This could result in poorer documentation quality for non-English speakers, potentially exacerbating existing disparities.
Patient trust represents another critical equity consideration. The authors note:
"Another important concern is that patient trust of ambient scribes may vary, and ambient scribes may be more likely to erode patient trust for patients from historically marginalized communities."
Patients with varying levels of technological literacy may have differential understanding and acceptance of risks to privacy or clinical outcomes. Research has demonstrated that racial attitudes affect physician-patient communication patterns, and ambient scribes introduce new complexity to these dynamics.
Finally, if ambient scribes do increase upcoding and healthcare utilization, the impact on revenues and access for safety-net providers serving vulnerable populations remains uncertain. This could either reduce or exacerbate existing disparities in both revenue generation and patient access.
The Path Forward
Despite the promise of reduced documentation burden, ambient scribes' broader implications for healthcare spending, quality, and equity remain uncertain and extraordinarily complex. The potential for automated upcoding and low-value care escalation, unknown effects on healthcare quality, and potential exacerbation of health disparities underscore an urgent need for careful surveillance as this technology proliferates throughout American healthcare.
The editorial authors conclude:
"It is imperative for policymakers, researchers, and health care system leaders to remain vigilant to ensure that these technologies achieve their goals to improve efficiency without causing more insidious impacts on the health care system."
As health systems continue rapid deployment of ambient scribes, rigorous evaluation must extend beyond documentation burden and satisfaction metrics. Comprehensive assessment should include systematic examination of coding practices, healthcare utilization patterns, clinical outcomes, cost trajectories, and equity impacts across diverse patient populations.
Policymakers face particular challenges in responding to this technology. Traditional regulatory approaches may prove too slow for the pace of AI evolution, while overly restrictive policies risk stifling innovation that could genuinely benefit patients and clinicians. Striking the appropriate balance will require ongoing dialogue among clinicians, health system leaders, payers, policymakers, and patients themselves.
For practicing physicians, the message is clear: ambient scribes offer legitimate benefits for documentation efficiency and potentially for patient engagement during clinical encounters. However, clinicians must remain aware of the technology's limitations, actively review AI-generated documentation for accuracy, maintain clinical accountability for all documented content, and advocate for transparent evaluation of the technology's broader impacts on healthcare delivery.
The technology's ultimate value will be determined not by its ability to reduce documentation time in isolation, but by whether it can do so while maintaining or improving clinical quality, controlling healthcare costs, and promoting rather than undermining health equity. Only rigorous, ongoing evaluation will answer these critical questions.
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