Enhancing Clinical Documentation Efficiency: Automating Notes Generation in a Lymphedema Clinical Decision Support System

Lymphedema is chronic swelling caused by fluid accumulation in the lymphatic system. If left unmanaged, it can lead to life-threatening complications. Effective clinical documentation is crucial in managing this condition, yet current processes are often time-consuming and redundant. Lymbase, a CDSS for lymphoedema management, is exploring the integration of an automated notes generation system to streamline clinical documentation.

This project explores the automated notes generation option for Lymbase to streamline clinical documentation. Through a scoping review and semi-structured interviews, we investigated available implementation options and user perspectives. The scoping review identified three primary approaches: AI-based systems, machine learning models, and template-based systems. AI-based models, such as large language models and hybrid AI approaches, demonstrated potential in producing high-quality clinical narratives but raised concerns about reliability and ethical implications. Machine learning-based systems provided flexible, scalable solutions but faced challenges related to data quality and real-world validation. Template-based systems, while transparent and easy to adopt, lacked the flexibility needed for complex documentation.

Semi-structured interviews with Lymbase users revealed that documentation inefficiencies were a significant barrier to workflow optimisation. Participants valued Lymbase’s automated calculations and data visualisation features but emphasised the need for improved integration of clinical note generation. They expressed interest in a system that could pre-populate progress notes using stored data while allowing manual customisation. Compliance with hospital policy and data security were also identified as critical considerations.

Addressing clinical documentation inefficiencies is critical. The increasing demand for healthcare services, coupled with the administrative burden placed on clinicians, necessitates the adoption of automated solutions. An automated notes generation system has the potential to reduce redundancy, improve documentation accuracy, and ultimately enhance patient care. This project lays the groundwork for implementing such a system, offering a solution that aligns with the evolving needs of lymphedema management and clinical support systems.