CDI’s Battle Against AI Hallucinations, Context Errors
By Elizabeth S. Goar
Following a checkup with his primary care physician, who used ambient listening tools to capture encounter notes, Medicomp System CMO Jay Anders, MD, was surprised to see diagnoses of atherosclerotic heart disease and diabetic complication listed in the clinical documentation. While he does have high blood pressure, he has never been diagnosed with heart disease, nor is there anything in his history that would account for the AI scribe inserting anything related to diabetes.
It’s a real-world example of how AI-generated documentation can be polished, structured, and compliant on its face, while silently misrepresenting what happened during the encounter. “That gap,” Anders says, “is where hallucinations live.”
Making the Distinction
Hallucinations occur when an AI system generates information that was never present in the source material. Clinical context errors can be more subtle. The information may exist somewhere in the record, but the AI interprets or applies it incorrectly.
“In my experience, clinical context errors can be particularly difficult to detect during human review because the individual facts may appear accurate on the surface. The problem is not necessarily that the AI invented information; it’s that it misunderstood the clinical context surrounding it,” says David Cohen, Greenway Health’s chief product and strategy officer.
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