1. Purpose and scope

This policy outlines the procedures and responsibilities for using AI scribe technologies (Tortus Scribe and Heidi Scribe and EMIS scribe) at Lonsdale Medical Centre. It ensures proper patient consent, data protection compliance, and clinical accountability in accordance with both national standards and NWL Integrated Care Board (ICB) guidance and policy.

2. Background

Lonsdale Medical Centre has implemented AI scribe solutions to reduce administrative burden and improve patient-clinician engagement during consultations. These technologies listen during consultations and generate draft clinical notes for clinician review before being entered into the patient’s record.

Use of these tools is aligned with Brent ICB guidance on digital innovation and data protection compliance.

3. Clinical responsibility

3.1 Ultimate responsibility

• Clinicians retain full responsibility for the accuracy, completeness, and appropriateness of all documentation entered into patient records.
• Use of AI scribe technology does not transfer or reduce clinical accountability.

3.2 Verification requirements

• Clinicians MUST review the full AI-generated transcription for accuracy and completeness before it is saved into EMIS.
• All clinical coding and medical terminology must be checked and adjusted as necessary.
• Errors or omissions must be corrected to ensure the documentation fully reflects the consultation.

3.3 Documentation procedures

• Currently, clinicians must manually copy and paste the verified text into EMIS.
• Future EMIS integration may streamline this, but verification requirements will remain unchanged.

4. Patient consent

4.1 Explicit consent requirement

• Explicit verbal consent MUST be obtained before using AI scribe tools during a consultation.
• Consent must be clearly documented in the patient’s medical record.

4.2 Consent procedure

Clinicians should provide a brief explanation to the patient at the beginning of the consultation, including:

• The purpose of using the AI scribe
• That the clinician will review the transcript before it is saved
• That use is optional and declining will not affect the quality of care

4.3 Consent statement

“We use AI technology to help document your consultation more efficiently, allowing me to focus more on our conversation. I will review everything it transcribes before adding it to your medical record. You are completely free to decline if you prefer we don’t use it today.”

4.4 Declining consent

If a patient declines, the clinician must:

• Document this in the patient record
• Not activate the AI scribe
• Use traditional note-taking methods
• Reassure the patient that their care will remain unaffected

5. Data protection and security

5.1 Data processing

• No voice recordings are stored by either Tortus or Heidi Scribe.
• Transcriptions are temporarily retained for up to 24 hours (unless deleted earlier).
• Clinicians must configure settings to ensure transcriptions are deleted after 24 hours.
• Deletion at the end of the session is strongly recommended.

5.2 Third-party access

• Tortus or Heidi staff may only access consultations with explicit clinician consent for support or troubleshooting.
• Such access must be documented, time-limited, and supervised if possible.
• Clinicians must lock screens when unattended and treat AI transcripts with the same confidentiality as patient records.
• Do not share login credentials, and ensure sessions are not conducted where others might overhear.

5.3 Training data usage

• Heidi may use anonymised data for system training.
• Tortus does not use consultation data for training.
• Patients should be informed of this if they inquire.

5.4 Legal and regulatory compliance

This policy supports Lonsdale Medical Centre’s compliance with:

• UK GDPR and the Data Protection Act (2018)

• The Access to Health Records Act (1990)

• NHS Digital Data Security and Protection Toolkit
• Brent ICB data governance policies

6. Implementation and training

6.1 Staff training

All clinicians must complete training covering:

• Consent procedures
• Proper system use
• Verification processes
• Data protection and confidentiality
• Recording patient preferences

6.2 Clinician acknowledgment

• Clinicians must sign a form confirming they have read, understood, and will follow this policy.
• Forms will be retained by the Practice Manager.
• Use of AI scribes is only permitted after training completion and acknowledgment submission.
• Annual refresher training is mandatory for all staff using AI tools.

7. Incident reporting

7.1 Reporting procedure

• Any concerns about data protection, consent, or transcription accuracy must be reported immediately to the Digital Lead and Practice Manager.
• Technical issues should be logged and escalated to IT support.

8. Policy review

This policy will be reviewed annually or earlier if significant updates to technology, regulations, or Brent ICB guidance occur.

9. Appendices

Appendix A: Quick reference guide

• Obtain and document explicit consent
• Use AI scribe during consultation
• Review entire transcription
• Correct and verify content
• Copy into EMIS
• Delete transcription after use (recommended) or within 24 hours

Appendix B: Patient information

See separate document: Patient Information Leaflet – Use of AI Scribe Tools at Lonsdale Medical Centre

10. Policy status

Policy version	Approved by	Date	Next review
1.0	Lonsdale GP Partners	1st April 2025	1st April 2026

This policy follows NWL ICB guidelines on digital health tools, patient consent, and data protection.