AI scribe and clinic software for gastroenterology clinics

The gastroenterology note, scored and coded

A new patient note in gastroenterology follows a set order. Presenting complaint and duration, bowel habit by the Bristol stool form scale, red flags asked and answered (weight loss, rectal bleeding, anaemia, nocturnal symptoms, family history), medicines including PPIs and NSAIDs, examination, and the tests already done. NICE advises a suspected cancer pathway referral for colorectal cancer when a FIT result is at least 10 micrograms of haemoglobin per gram of faeces,³ and recommends faecal calprotectin to help tell IBD from IBS in adults with recent lower GI symptoms when cancer is not suspected.² When the gastroenterologist reads those values aloud, the draft records the number, the unit and the date.

An IBD review carries more structure. Extent and behaviour by the Montreal classification, a clinical index (the Harvey-Bradshaw index for Crohn's disease, the partial Mayo score or the Simple Clinical Colitis Activity Index for ulcerative colitis), haemoglobin, CRP and faecal calprotectin, then the current therapy and its monitoring bloods. The British Society of Gastroenterology recommends that multimodal approach to monitoring ulcerative colitis, and advises that a calprotectin above 200 μg/g should prompt a discussion about lower GI endoscopy.¹ A clinic template holds those fields in place, so the index and the markers land in the same order at every review.

Codes are suggested from the note, each shown with the line of the consultation it rests on, for the gastroenterologist to confirm. Typical suggestions in ICD-10, the edition used in the UK and the Gulf, are K50.9 Crohn disease, unspecified, K51.9 Ulcerative colitis, unspecified, K21.9 Gastro-oesophageal reflux disease without oesophagitis, K58.1 Irritable bowel syndrome with predominant diarrhoea, K90.0 Coeliac disease and K22.7 Barrett oesophagus. US practices see the ICD-10-CM forms, which differ in places, for example K50.90 for Crohn's disease, unspecified, without complications, and K58.0 for irritable bowel syndrome with diarrhoea. SNOMED CT concepts are suggested alongside. Procedure codes for colonoscopy and gastroscopy, CPT in the US and OPCS in the UK, stay with the clinic's coder.

The endoscopy report itself is written in the endoscopy reporting system in the procedure room, with its photographs and quality fields, and wai does not write it. wai covers the consultations on either side, the clinic visit that decides on the procedure and the results appointment after histology, where the gastroenterologist summarises the report aloud and the draft carries that summary into the letter.

The letters a gastroenterology clinic sends, and to whom

The Academy of Medical Royal Colleges recommends that most outpatient letters are written to the patient with a copy to the GP, and says writing to patients should be the default setting for an AI scribe.⁴ In gastroenterology that letter explains the working diagnosis in plain words, which tests come next and why, and what to do if symptoms change, with the GP copied for prescribing and blood monitoring.

The endoscopy referral goes to the endoscopy unit or the colleague doing the procedure. It carries the clinical question, the anticoagulant and diabetes medicine plans and the consent points already discussed. The results letter follows histology, to the patient with copies to the GP and the referrer, and sets out the surveillance interval where one applies. The BSG asks that every patient starting an advanced therapy receives written information about benefits, risks, side effects and the monitoring schedule,¹ and the letter drafted from the consultation carries what was actually discussed. Medication change letters cover a new mesalazine dose, a thiopurine adjustment or a steroid taper, step by step.

Referral letters onward, to a colorectal surgeon, a dietitian or a hepatologist, carry the question for the specialist and are drafted from the whole record. The structure is set out in the referral letter, and the surgical side of the pathway in AI scribe for general surgery.

Gastroenterology in the patient's own language

wai captures consultations in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in the same consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in the language spoken.

Bowel symptoms are where patients reach for their own words. A history of blood, urgency or incontinence is more complete when the patient gives it in the language they think in. The signed note is written in English for the record, or in another language the clinic chooses, and the patient summary, with the new doses and the bowel preparation advice, can go home translated beside it. Crisis and emergency numbers stay exactly as written. More on this in multilingual consultations and on the multilingual AI scribe page.

Clinic software for gastroenterology clinics, from referral to recall

A private gastroenterology clinic runs on referrals, procedures and monitoring. In wai Admin, calls, email, web forms and WhatsApp messages land in one thread per patient, and replies are drafted in the clinic's voice for a person to approve before they are sent. Patients request appointments through booking links that read each consultant's calendar, cancellations backfill from the waitlist, and reminders go out. Endoscopy deposits, invoices, payment links and insurer invoices run through the clinic's own Stripe account.

Monitoring is where a gastroenterology clinic loses track. Proactive care sends the recall for the repeat calprotectin, the thiopurine monitoring bloods or the surveillance colonoscopy, each message approved by a person. In the UK, pathology orders go out and results come back through TDL, and private prescriptions are issued and signed through SignatureRx. Each result reaches the patient with the doctor's own comment and a plain explanation of each marker, and the after-visit companion tracks each referral, prescription and follow-up until it is done.

Before the next review, the gastroenterologist sees a sourced brief of the patient, each fact traced to the letter, result or visit it came from, so the last calprotectin and the last scope are on screen before the patient sits down. The full front desk is described on the clinic management software page.

One IBD review, start to finish

Take a 34-year-old with ulcerative colitis, on mesalazine for three years, seen after six weeks of looser stools, five a day with some blood and urgency. The gastroenterologist asks about stool frequency, bleeding, nights and joint or eye symptoms, scores the partial Mayo items aloud, and reads last week's results, a calprotectin of 640 μg/g, haemoglobin of 118 g/L and a CRP of 14 mg/L. They agree a flexible sigmoidoscopy, a higher mesalazine dose with a rectal preparation, and a conversation about advanced therapy at the next visit if the flare does not settle.

The draft note holds the history in order, the partial Mayo items and total, the three results with units and dates, the plan and the advice on when to call the clinic. The suggested code is K51.9 Ulcerative colitis, unspecified, tied to the line where the diagnosis was discussed. The gastroenterologist corrects the rectal preparation from suppository to enema, which the draft had misheard, checks the partial Mayo total, confirms the code and signs.

Three documents go out. The letter to the patient explains the flare, the new doses and the sigmoidoscopy, with a copy to the GP. The endoscopy referral asks whether the colitis has extended and records that the patient takes no anticoagulant. A medication change letter sets out the new mesalazine dose. The front desk sends the booking link for the sigmoidoscopy, takes the deposit through Stripe and sets a recall for a repeat calprotectin in eight weeks, approved by a person before it goes.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁵ At The Permanente Medical Group, 3,442 physicians used an ambient scribe across 303,266 encounters in its first ten weeks.⁶ wai is built on that finding, so it takes on the letters, the recalls and the bookings as well as the note.

Gastroenterology's own guidance asks for structure. The BSG recommends a clinical index with haemoglobin, CRP and calprotectin at ulcerative colitis reviews, and written information for every patient starting an advanced therapy.¹ A template that holds those fields makes the guidance the default rather than a memory test.

A draft stays a draft until a person signs it. The Academy of Medical Royal Colleges says the clinician checks every document a scribe produces,⁴ and wai holds every draft until the gastroenterologist signs it. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁷

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁸

Where to start

Start with one consultant's IBD review list. Build the review template with the clinical index, the three markers and the therapy monitoring fields, run it for the first week, and count corrections to scores, doses and units. In the second week, add new patient letters and the endoscopy referral, and switch on the calprotectin and monitoring recalls in wai Admin.

Read how to judge AI scribe accuracy before the pilot, and compare other specialties on the specialties hub. The scribe is described on the wai Clinicians page, and prices are on the pricing page.

Frequently asked questions