Ambient Clinical Documentation & SMART on FHIR Integration
Ambient AI Medical Scribe
A medical-grade transcription and summarization engine that produces CMS-aligned SOAP notes and injects them into Epic/Cerner securely via SMART on FHIR.
The Challenge
Physicians spend a large share of their day on documentation burden—typing SOAP notes after visits—creating “pajama time,” burnout risk, and reduced patient satisfaction.
The solution required a mobile recording interface that survives noisy exam rooms and produces notes that adhere to CMS coding guidelines. It also needed strict privacy controls: zero-retention audio processing, secure EHR write-back, and accurate medication/dosage capture to avoid clinical risk.
Quick Stats
- Integration: SMART on FHIR (Epic/Cerner)
- Audio: Zero-retention processing
- AI: Whisper v3 + GPT-4o-Med
- Impact: 70% less documentation; +2 patients/day
The Solution
We built a medical-grade transcription and summarization engine. The app captures ambient doctor-patient conversation and uses specialized models to extract clinical facts into a structured SOAP format.
Clinicians get a low-friction workflow: record naturally, review a clinician-style SOAP note, then inject it into the EHR via SMART on FHIR—while audio is deleted immediately after processing and all sensitive handling is SOC 2 aligned.
Technical Approach
- Speaker diarization: Audio pipeline distinguishes clinician vs patient speech so SOAP sections remain accurate.
- Medical NER: Models identify medications, dosages, and ICD-10 codes from natural speech.
Technical Details
Architecture
React Native → Whisper v3 (Large) → GPT-4o-Med (fine-tuned)
Integrations
SMART on FHIR for one-click note injection into Epic and Cerner.
Security
Zero-retention audio (deleted immediately after processing); SOC 2 aligned; end-to-end encryption.
AI Features
Automatic ICD-10 coding suggestions to reduce claim denials and speed billing workflows.
Results & Impact
- 70% less documentation time: saving doctors ~2 hours per day.
- 2 extra patients per day without extending clinic hours.
- Zero errors in medication and dosage capture.