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How Cogninest AI Powers AI-Driven Medical Notes & Code Extraction for Billing?

Client and Challenge

GGZ Noord-Holland-Noord, a leading mental health organization, was facing a significant administrative challenge that was affecting the efficiency of its healthcare professionals. Clinicians were spending excessive amounts of time on manual documentation tasks, including transcribing doctor-patient consultations, summarizing clinical notes, and assigning International Classification of Diseases (ICD) codes. These processes were not only time consuming but also prone to human errors, which could impact the accuracy of medical records and delay patient care.

As the volume of consultations increased, the burden of documentation became even more overwhelming. Healthcare professionals had to split their attention between providing quality care and keeping up with administrative requirements, leading to burnout and inefficiencies. Additionally, the lack of automation made it difficult to maintain standardized records, which are crucial for accurate medical billing, compliance, and effective patient management.

Recognizing the urgent need for a streamlined solution, GGZ Noord-Holland-Noord sought an innovative approach to automate clinical documentation. Their goal was to implement an AI-driven system that could transcribe consultations with high accuracy, generate structured clinical summaries, and automatically extract ICD codes, all while integrating seamlessly with Electronic Health Records (EHRs). This would not only reduce the administrative workload but also ensure consistency, improve documentation accuracy, and allow clinicians to focus more on direct patient care.

Solution

To address the growing administrative burden in clinical documentation, Cogninest AI developed a cutting edge AI-powered solution for GGZ Noord-Holland-Noord. Our system automates transcription, clinical summarization, and ICD code extraction, significantly reducing the workload for healthcare professionals while ensuring high accuracy and seamless integration with Electronic Health Records (EHRs).

At the core of our solution is a Custom Fine Tuned Whisper Model, which transcribes doctor-patient interactions with remarkable precision, preserving every critical detail. Once transcribed, the text is processed by our Custom Fine Tuned LLM with QLoRA (Qwen2.5 8B, hosted using vLLM) to generate structured and concise clinical summaries. These summaries accurately capture patient conditions, symptoms, diagnoses, and treatment plans, making documentation faster and more reliable.

To further streamline medical workflows, we implemented Automated ICD Code Extraction, which assigns the correct ICD codes to each case, simplifying billing and compliance.

Our intuitive user interface empowers clinicians with easy to use tools to review, edit, and finalize summaries. With features like font adjustments, copy/cut options, and an intuitive approval process, healthcare professionals can effortlessly mark records as “Ready for EHR”, ensuring a smooth transition into digital health systems.

By partnering with GGZ Noord-Holland-Noord, Cogninest AI has successfully transformed clinical documentation, enabling clinicians to focus more on patient care while maintaining accurate and efficient medical records.

Highlights

1. AI-Powered Audio Transcription: Converts doctor-patient conversations into text with high accuracy.
2. Clinical Summary Generation: Automatically creates structured summaries capturing key details like diagnoses and treatment plans.
3. ICD Code Extraction: Ensures proper classification of diseases for accurate medical billing.
4. Editable Summaries: Clinicians can refine AI-generated summaries with features like font size adjustment, copy/cut functionality, and annotations.
5. Seamless EHR Integration: Finalized summaries can be directly pushed into electronic health record systems.
6. Privacy and Security Features: Patient data is protected through anonymization and robust security measures.

Result

The implementation of this AI-powered documentation tool has transformed clinical workflows at GGZ Noord-Holland-Noord. Key benefits include:

• 70% reduction in time spent on documentation: Clinicians now spend more time with patients rather than on paperwork.
• Improved accuracy of clinical records: AI-driven transcription and summarization minimize errors.
• Faster and more efficient ICD coding: Automating this process has streamlined medical billing and compliance.
• Seamless adoption by healthcare professionals: The user friendly interface ensures smooth integration into existing workflows.

Tech Stack

The system is powered by a combination of cutting edge AI models and cloud based deployment solutions:

• AI Models:
• Custom fine tuned Whisper for transcription.
• Custom fine tuned LLM with QLoRA (Qwen2.5 8B, hosted using vLLM) for summarization.
• Programming & Frameworks:
• Python (FastAPI, Flask)
• React.js for the front-end UI
• Cloud Infrastructure:
• AWS for scalable and secure deployment
• Security Features:
• Data anonymization
• End-to-end encryption

Testimonial

"This AI-powered documentation system has been a game-changer for us at GGZ Noord-Holland-Noord. The time saved on administrative tasks allows our clinicians to focus on what matters most patient care. The accuracy and efficiency of the solution have significantly improved our clinical workflows."

At Cogninest AI, we specialize in helping companies build cutting edge AI solutions. To explore how we can assist your business, feel free to reach out to us at team@cogninest.ai