AI Native Clinical Copilot for Documentation & Decision Support

CARE is an AI native clinical copilot platform designed to reduce documentation burden, provide real-time decision support, and streamline downstream administrative workflows for healthcare providers.

AIHealthcareSaaSEHR
View Figma Presentation (opens in a new tab)
Clinician time saved
45 hr/wk
Medical coding automated
90%
Revenue influenced
$500K
Increase in revenue
21%

Overview

Executive Summary

CARE is an AI native clinical copilot platform designed to reduce documentation burden, provide real-time decision support, and streamline downstream administrative workflows for healthcare providers. The product integrates directly with existing clinical systems and EHRs, enabling ambient documentation and AI assistance without disrupting clinician-patient interactions.

This project documents my work on the early design and foundational clinician experience for CARE, with a focus on workflow alignment, explainability, and scalable personalization across specialties. The goal was to design AI assistance that functions as background infrastructure supporting clinical work without adding cognitive or interaction overhead.

Ambient recording of a patient visit feeding an Ask AI panel and AI-suggested clinical notes

Problem

Navigating Unprecedented Pressures

Documentation is no longer a record of care. It is a second job running alongside it, and four pressures shaped what CARE had to answer.

  • Excessive Documentation

    Clinicians spend up to 16 hours weekly on documentation, the heaviest load in protocol-driven care.

  • Data Accuracy Concerns

    Generic EHR templates misrecord the device settings and dosing that specialty care turns on.

  • Heightened Burnout Risks

    Burnout runs 15% higher where the documentation load is heaviest, driven by EHR admin work.

  • EHR Workflow Issues

    40% of clinicians report dissatisfaction with their EHR, citing lost efficiency at every step.

EHR Reality

Designed Around Data, Not Decisions

Before designing anything I spent time in the systems clinicians already work in: athenahealth, Epic, Cerner, NextGen and Kareo, read against documentation standards from the AMA and from health systems like Mount Sinai. Two screens stand for the rest.

Both capture structured data reliably, and neither helps anyone decide what to do next. Every field is accounted for and nothing is ranked. The clinical picture is spread across a dozen modules, and assembling it is work that falls to the clinician between patients. That is the surface CARE had to sit on top of, and the reason it had to earn its place without asking for a new one.

  • athenahealth
  • Epic Systems
  • Cerner
  • NextGen Healthcare
  • Kareo, a Tebra company
  • American Medical Association
  • Mount Sinai Health System
Systems and standards reviewed

Landscape

Fragmented Solutions, Persistent Gaps

The market had already answered parts of this. Each answer solves the step in front of it and leaves the next one open, which is why the load never moves.

  • Human Scribes and Coders

    Accurate on entry, but expensive to staff and thin on the specialty detail that matters.

  • Template Documentation

    One size fits all, so the details that define a case fall outside the fields on offer.

  • UI Wrappers on LLMs

    Fluent until the terminology turns specific, where device and dosing detail goes wrong.

  • Piecemeal Solutions

    Each one fixes a single step, and none of them close the loop across a whole encounter.

Scope

Scope of Work

  • Documentation

    Clinician facing capture and review workflows across the whole encounter.

  • Real-time Support

    Decision support offered during the visit rather than after it closes.

  • Human in the Loop

    Control and validation at every point the model proposes something.

  • EHR Integration

    The experience of sitting inside the systems clinicians already work in.

Approach

Design Principles

The design approach centered on creating AI assistance that functions as background infrastructure supporting clinical work without adding cognitive or interaction overhead. Four principles held the work to it.

  • Workflow Alignment

    Features that fit the workflow a clinician already has, rather than running beside it.

  • Explainability

    Suggestions that show their reasoning and their source, so trust is earned not assumed.

  • Scalable Personalization

    Adapts to a clinician over time while holding one standard across every specialty.

  • Minimal Cognitive Load

    No new tool to manage, so attention stays on the patient rather than the assistant.

Workflow

Navigating a Fragmented Care Journey

The clinician workflow was mapped across the full encounter lifecycle to find where friction accumulates and where CARE could take work off the clinician without disrupting the patient in front of them.

The same six stages carry four readings each: what the clinician does, what they have to touch to do it, what it costs them, and how much of their attention the stage takes. Follow the cognitive load across the six and the shape of the day appears: it is not one bad moment, it is context switching that never resolves and work that follows them home.

  1. Stage 1

    Scheduling & Calendar Review

    Does

    • Review the daily schedule
    • Assess visit types and workload
    • Adapt to cancellations and overbooking

    Touches

    • EHR scheduling
    • Calendar
    • Front desk

    Costs

    • Limited visibility into visit complexity
    • Schedule changes are handled reactively
    • No predictive support for disruptions

    Cognitive load

    Moderate

    Anticipatory stress, Planning overhead

  2. Stage 2

    Pre-Visit Chart Review

    Does

    • Read patient history and prior notes
    • Check labs, medications and recent changes
    • Identify the context relevant to today

    Touches

    • Patient chart
    • Medication history
    • Labs and results

    Costs

    • Information fragmented across modules
    • No concise patient snapshot
    • Relevant context requires manual synthesis

    Cognitive load

    Elevated

    Information synthesis, Time pressure

  3. Stage 3

    Encounter & Documentation

    Does

    • Interview and examine the patient
    • Capture clinical findings
    • Document history, assessment and plan

    Touches

    • Patient interaction
    • EHR templates
    • Clinical notes

    Costs

    • Documentation competes with patient attention
    • Rigid templates disrupt the natural flow
    • Frequent navigation and task switching

    Cognitive load

    High

    Divided attention, Working memory burden

  4. Stage 4

    Coding & Billing

    Does

    • Select diagnosis and procedure codes
    • Check the note supports the coding
    • Review for billing completeness

    Touches

    • Coding module
    • Clinical documentation
    • Billing workflows

    Costs

    • Codes surfaced apart from clinical context
    • Manual translation from note to code
    • Compliance requirements add complexity

    Cognitive load

    High

    Administrative burden, Compliance anxiety

  5. Stage 5

    Orders & Follow-Ups

    Does

    • Place lab and imaging orders
    • Prescribe medications and create referrals
    • Coordinate follow-up actions

    Touches

    • Orders
    • Prescriptions
    • Referrals and scheduling

    Costs

    • Actions distributed across separate workflows
    • Repeated context switching
    • Follow-up coordination stays manual

    Cognitive load

    Elevated

    Decision fatigue, Friction accumulation

  6. Stage 6

    End-of-Day Wrap-Up

    Does

    • Complete unfinished notes
    • Review pending tasks and results
    • Sign and close encounters

    Touches

    • EHR inbox
    • Task queues
    • Documentation dashboard

    Costs

    • Incomplete work accumulates through the day
    • Limited visibility into what is outstanding
    • Documentation extends beyond clinical hours

    Cognitive load

    High

    Mental fatigue, Burnout accumulation

Stakeholders Alignment

Cross-functional perspectives were gathered to clarify priorities, constraints, and success criteria across groups. Each function evaluates the product through a distinct lens, including clinical efficiency, system stability, financial performance, and scalability.

Key Findings

StakeholderWhat They Care AboutAlignment Focus

Clinicians

  • Reduce documentation burden
  • Protect patient interaction
  • Structured documentation
  • Ambient AI
  • Minimal workflow disruption
  • Human control

IT / EHR Teams

  • Stable integration
  • System performance
  • Seamless EHR integration
  • Low technical overhead

Compliance / Billing Teams

  • Coding accuracy
  • Reduced denials
  • Structured data capture
  • AI-assisted coding

Executive Leadership

  • ROI
  • Scalability and Adoption
  • Measurable impact
  • Configurable platform

User Persona

Understanding Real-World Clinical Behaviours

Mary George

Mary George

Medical Director, Personalized Wellness Internal Medicine

Age
59
In practice
20+ years
Specialty
Internal medicine

An experienced physician balancing patient care against clinical and administrative load. She wants fast access to the context that matters for the patient in front of her, and fewer screens between her and it.

  • Goals

    • Spend more of the day on patients than on administration
    • Understand a patient’s history before the encounter, not during it
    • Decide with the relevant context already at hand
  • Pain Points

    • Critical information is scattered across EHR screens
    • Documentation and coding run well past the visit
    • Repeated navigation and task switching accumulate
  • Behaviour

    • Reviews charts and recent results before each encounter
    • Documents during the visit, finishes notes between appointments
    • Works to established routines and resists disruption to them
  • Needs

    • A concise, clinically relevant summary before every encounter
    • Documentation and coding that adapt to how she already works
    • One workspace for context, actions and follow-ups

User Flow

Designing a Seamless Clinical Journey

The flow follows one visit end to end, from opening the day to handing the next patient back to the schedule. The AI stages are the three places CARE does work the clinician would otherwise do by hand, and every one of them ends in something she reviews rather than something she receives.

The visit in four phases. Reach the patient: login, the day’s dashboard, select patient, patient profile. Run the encounter: an AI pre-visit review of history, medications, labs and care gaps, then start visit, an AI-assisted ambient encounter, and end encounter. Draft and verify: AI generates a clinical note with suggested diagnoses and ICD and CPT codes, which she reviews and edits, and a decision — accurate confirms and continues, inaccurate returns to edit or regenerate. Close the loop: orders and next steps for medications, labs and referrals, review and sign, complete visit, sync to EHR, and back to the dashboard for the next patient.

Demo

Product Walkthrough

An interactive walkthrough of the clinician experience is available below, showcasing the core workflows and AI-assisted features designed for CARE.

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