[4 min read]

Welcome back to The Sullivan Group’s Spring Newsletter! It’s been a while—five years, to be exact—since our last edition. A lot has changed, and it's time for TSG to re-engage and bring emergency medicine risk and safety back into focus.With technology evolving rapidly and artificial intelligence (AI) rushing into real-time clinical workflows, this is a critical moment to pause and refocus on what matters most: keeping patients safe and minimizing liability for practitioners and healthcare organizations.

Though we’ve been quiet on the newsletter front, TSG has remained deeply engaged behind the scenes. One key area of ongoing work has been our evaluation of emergency departments across the country, with a particular focus on the quality of clinical documentation. Over time, we’ve witnessed a steady decline in documentation quality—from paper-based templates like T-Sheets, through EMRs built for emergency medicine, to today’s dominant platforms like EPIC, Cerner, and Meditech, and now into the age of ambient speech recognition.

Two decades ago, most EM practitioners used paper templates that included built-in documentation prompts and risk-safety nudges. TSG’s own PromptCharts™ were designed to do exactly that—enhance safety and reduce variability. But modern EHRs have replaced these structured tools with free-text fields. Now, with AI-driven ambient speech systems generating charts from bedside conversations, those cognitive safety cues have all but disappeared—and with them, the consistency and completeness of documentation.

This matters. TSG has consistently shown that when practitioners reliably document key historical and physical exam findings—those that influence likelihood ratios for disease—patient outcomes improve, and malpractice risks drop. Veteran clinicians will tell you: the key to diagnosis is in the history.

Now, imagine the contrast between a practitioner guided by a chest pain template that highlights lists of critical risk factors—CAD, PE, AoD—and one speaking freely while an AI builds the chart. Without reference points, reminders, or prompts, vital questions go unasked. Diagnoses are missed. Failure to diagnose increases.

True quality improvement stems from reducing variability and building reliable processes—principles at the heart of Lean and Six Sigma. Ambient AI documentation, in its current form, moves us in the opposite direction. It invites randomness and inconsistency. It’s not progress—it’s entropy.

This trend is further amplified by CMS’s 2023 coding guidance, which downplays the importance of history and physical exam documentation. The result? A system that no longer incentivizes thoroughness. A perfect storm? Perhaps.

All that said, there are clear benefits to employing AI in the workflow. For providers, the automation of documentation using AI allows for immediate note generation following a patient encounter. This reduces cognitive load and minimizes the burden of electronic health records (EHRs). As a result, clinicians can dedicate more time to bedside care and build stronger patient relationships. The shift away from administrative work toward more meaningful patient interaction may even increase job satisfaction and the joy of practice.

TSG has actively partnered in the development of emergency medicine ambient speech and AI systems, and we’re here to say: if you’re going to automate documentation and billing, you must also automate performance improvement. Otherwise, we risk undoing decades of progress in patient safety and risk reduction.

We’re still in the fight—and more committed than ever.