Auto-generating clinical documentation from consultations

Purpose

1.1. To automate the generation of detailed clinical documentation following immunology consultations, ensuring completeness, accuracy, and speed in healthcare records.
1.2. Automates converting spoken or written clinical notes into structured EHR-compatible reports.
1.3. Supports automating the pre-population of forms, templating, and codified data for regulatory compliance and quality care tracking.

Trigger Conditions

2.1. Automation begins once a consultation is completed and a digital/audio record is created.
2.2. Alternative trigger: physician submits note via EHR or mobile app.
2.3. Automatedly triggered by scheduling workflow, task status, or voice command from a clinician.

Platform Variants

3.1. Epic
• Feature/Setting: Use "FHIR API: DocumentReference/Composition" to automate pushing generated documents into patient records.

3.2. Cerner
• Feature/Setting: Automates "PowerChart API: Clinical Note Automation" for ingesting structured documentation.

3.3. Microsoft Azure Speech Services
• Feature/Setting: "Speech-to-Text Real-Time Transcription" automating clinic conversations into text for further parsing.

3.4. Google Cloud Healthcare API
• Feature/Setting: "FHIR Store: Create/Update Document" automates conversion from notes to EHR documents.

3.5. AWS Comprehend Medical
• Feature/Setting: "DetectEntitiesV2" API automates extracting immunologic terms for categorized documentation.

3.6. OpenAI GPT API
• Feature/Setting: "Completion" automates summarizing and structuring clinical dialogues into standardized documentation.

3.7. Dragon Medical One
• Feature/Setting: "Real-Time Speech Recognition & Auto Note Creation" automates clinical dictation into formatted notes.

3.8. Meditech Expanse
• Feature/Setting: "NPR/Integration Engine" automates ingestion and documentation of clinical content.

3.9. Salesforce Health Cloud
• Feature/Setting: "Health Cloud APIs – Care Plan Dataset" automates updating and appending to patient clinical records.

3.10. Notable Health
• Feature/Setting: "Automated Clinical Documentation Workflow" automates data capture, summary, and EHR sync.

3.11. Nuance DAX
• Feature/Setting: "Ambient Voice Capture & Automated Note Generation" automates contextual understanding and structured documentation.

3.12. Apple HealthKit
• Feature/Setting: "Health Data Upload API" automates pushing documentation summaries from iOS devices into EHR.

3.13. Redox
• Feature/Setting: "Notes Write API" automates transferring standardized clinical documentation across systems.

3.14. athenahealth
• Feature/Setting: "Clinicals API – Encounter Documentation" automates documentation upload and reconciliation.

3.15. IBM Watson Health
• Feature/Setting: "Discovery – Natural Language Processing" automates extraction and enrichment of clinical documentation.

3.16. InterSystems HealthShare
• Feature/Setting: "FHIR Clinical Documentation API" automates incoming document processing.

3.17. Mediscribe
• Feature/Setting: "Speech to EHR Documentation Automation" automates completion of consult templates.

3.18. Suki AI
• Feature/Setting: "Voice-Driven Documentation Automation" automates translation of spoken notes into formatted EHR entries.

3.19. Availity
• Feature/Setting: "Clinical Gateway API" automates documentation updates and payer communication.

3.20. CareCloud
• Feature/Setting: "Clinical Documentation API" automates integration and updating of immunology consult data.

Benefits

4.1. Automates repetitive data entry and reduces clinician burnout.
4.2. Automatedly improves documentation accuracy, standardization, and compliance.
4.3. Enables faster revenue cycles by automating the timely submission of complete records.
4.4. Automates interoperability between disparate EHR, clinical, and analytic systems.
4.5. Automated documentation improves data-driven decision making and population health management.