Reducing Clinical Documentation time with AI-Powered Workflows

Clinicians spend 2+ hours daily typing notes, often during patient encounters, breaking eye contact and diminishing the human connection that's fundamental to care.

The Innovation: AI Note+ (Ambient Listening)

Led the design and GTM activities of AI Note+, a revolutionary ambient listening system that fundamentally transforms how clinical documentation happens:

Intelligent Voice Capture & Processing:

• Ambient recording that naturally captures patient-provider conversations without disrupting the flow of care

• Real-time AI transcription with medical terminology recognition and context awareness

• Smart speaker diarization that distinguishes between provider, patient, and family voices

• Automatic note structuring that transforms conversations into properly formatted SOAP notes

• Context-aware sections that populate HPI, ROS, Physical Exam, and Assessment/Plan based on conversation content

AI-Powered Intelligence Features:

• Clinical entity extraction identifying medications, conditions, symptoms, and procedures mentioned

• Temporal reasoning that understands "since last Tuesday" or "for about 2 weeks"

• Negation detection recognizing "no fever," "denies chest pain," etc.

• Automated coding suggestions for CPT and ICD-10 based on documented encounter

• Care gap identification flagging missing screenings or follow-ups mentioned during visit

Design Philosophy: Invisible Yet Transparent

The core principle behind AI Note+ is that documentation should be invisible during the encounter but transparent in its process. The AI works quietly in the background while maintaining complete clinician control and oversight.

Key UX Innovations

Persistent Recording Indicators:

• Red recording banner visible across all screens - providers always know when ambient listening is active

• Subtle pulsing animation that confirms active recording without being distracting

• One-tap pause/resume for private discussions or sensitive moments

• Duration counter showing recording length for billing documentation

Trust Through Transparency:

• AI confidence scoring on each generated section (high/medium/low)

• Source attribution linking generated text back to specific conversation moments

• Edit tracking showing what AI generated vs. what clinician modified

• Learning indicators when AI adapts to individual provider preferences

Seamless Review Workflow:

• Side-by-side view of transcript and generated note

• Quick correction tools for common AI mistakes

• Template integration preserving existing documentation preferences

• One-click acceptance for accurately generated sections

Rapid Prototyping with Clinicians

My approach centered on direct collaboration with practicing physicians, using AI-powered design tools to iterate in real-time:

• Shadow sessions observing actual patient encounters to understand conversation flow

• Live testing with physicians using prototypes during simulated visits

• Real-time adjustments modifying the AI prompts and UI based on immediate feedback

• Voice pattern analysis to optimize for different speaking styles and accents

• Specialty-specific customization for pediatrics, internal medicine, and specialists

The AI Architecture Behind the Experience

Multi-Model Approach:

• Primary transcription model for accurate medical speech-to-text

• Clinical NLP model for entity extraction and relationship mapping

• Note generation model fine-tuned on thousands of clinical notes

• Quality assurance model checking for inconsistencies and errors

Privacy & Compliance First:

• On-device processing options for sensitive encounters

• HIPAA-compliant data handling with automatic PHI detection

• Consent workflows built into the patient check-in process

• Audit trails for all AI-generated content

Impact & Real-World Results

Quantitative Outcomes:

• 60% reduction in documentation time (from 10 minutes to 4 minutes per encounter)

• 40% decrease in after-hours "pajama time" documentation

• 85% first-pass accuracy requiring minimal editing

• 92% provider satisfaction in pilot programs

Qualitative Transformations:

• Providers report "feeling like doctors again" with restored eye contact

• Patients feel more heard and engaged during visits

• Reduced physician burnout scores

• More detailed and comprehensive documentation

Complementary Innovation: Smart Ordering

While AI Note+ handles documentation, our Smart Ordering System streamlines the ordering process with AI-powered predictions and context-aware suggestions, creating a complete AI-enhanced clinical workflow. Together, these tools save providers over 20 minutes per patient encounter.

Why This Matters

AI Note+ represents a paradigm shift in clinical documentation. By removing the keyboard from the examination room, we're not just saving time – we're fundamentally restoring the human connection in healthcare. Physicians can focus entirely on their patients, knowing that AI is capturing and structuring the encounter accurately in the background.

This isn't about replacing clinical judgment with AI – it's about using AI to eliminate the mechanical aspects of documentation so providers can focus on what they do best: practicing medicine.

Technologies: Azure Cognitive Services, OpenAI GPT-4, Custom Clinical NLP, WebRTC, React, TypeScript, FHIR

Methodologies: Ambient Computing Design, Shadow Observation, Real-Time Clinical Testing, AI-Assisted Rapid Prototyping