AI solution for clinical encounter documentation automation

Itransition developed an AI-powered add-on for Microsoft Cloud for Healthcare that accelerates encounter notation during telehealth consultations and improves care quality through automating clinical documentation. The add-on is built to support healthcare businesses of all sizes - from small and mid-sized organizations to large enterprises and is designed to comply with applicable regulations in the USA and the EU.

6 min

saved per patient interaction

75%

doctors reported a higher quality of the medical history

60%

patients reported more engaging consultations

15%

fewer disputed invoices due to billing accuracy improvements

AI solution for clinical encounter documentation automation

All technologies used

AI Agents

Microsoft Cloud for Healthcare

Microsoft Teams

Azure

The context

With deep expertise in the healthcare domain, Itransition has been delivering healthcare management, ERP, CRM, telehealth, mobile health, and IoT solutions to healthcare organizations of all sizes for many years. Many of these solutions are built on Microsoft technologies, supported by Itransition’s long-standing partnership with Microsoft since 2008.

Over time, Itransition has gained an understanding of the operational challenges faced by the industry and recurring pain points common to healthcare providers. At some point, the company decided to create a ready-to-use solution that could be offered broadly to healthcare organizations seeking to modernize their operations.

Industry

Software & hi-tech

Founded

1998

Operational footprint

North America, Europe, the Middle East, and Asia

Clients

1,100+ across 40 countries

The challenge

Itransition noticed that many healthcare providers struggle with excessive administrative tasks, significantly reducing the time clinicians can dedicate to patient care. Manual clinical documentation of patient encounters appears to be a major pain point, consuming a substantial portion of clinicians’ time and negatively impacting clinical productivity. In addition, it can contain missing details, inconsistencies, typos, and omitted indicators, which lead to issues with invoicing and reimbursement.

The solution

Itransition developed a voice-enabled AI tool using Azure OpenAI that seamlessly integrates with Microsoft Cloud for Healthcare and Microsoft Teams. The solution supports automated clinical documentation by analyzing audio from a doctor-patient interaction during a Microsoft Teams consultation and generating structured SOAP (Subjective, Objective, Assessment, and Plan) notes.

Data is automatically added into predefined medical record fields, so doctors only need to review it, make corrections, and approve the generated report. Once finalized, the note is added to the encounter and is saved in the patient’s medical records.

The AI clinical note automation solution received approval on AppSource, Microsoft's marketplace for certified business solutions. The certification validates the application’s compliance with quality, technical, security, and performance standards, as well as seamless integration with Microsoft platforms such as Office 365, Dynamics 365, and Azure. The add-on is also compatible with other healthcare solutions within the Microsoft ecosystem, enhancing interoperability and ensuring broader adoption across healthcare organizations.

Benefits for healthcare organizations

  • Higher throughput and operational efficiency
    With encounter documentation automation, clinicians spend less time on note-taking and post-visit paperwork, which allows them to complete visits faster, reduce overtime, and see more patients per day without increasing workload or compromising care quality.
  • Elevated patient experience
    With less attention split between patient care and documentation, doctors can focus more on the conversation with the patient, listening, explaining treatment plans, and addressing concerns. It increases patient trust and satisfaction.
  • Documentation that directly supports billing accuracy
    Consistent and detailed capture of diagnoses, procedures, and clinical decisions minimizes the risk of missed details or documentation errors. This reduces coding rework, prevents missed billable services, lowers denial rates, and helps organizations receive timely and accurate reimbursement.

The solution has already been integrated across several healthcare organizations, delivering tangible business outcomes:

  • Large US-based hospital managing 1,000 daily patient visits reduced average clinician documentation time per visit by 35%, allowing doctors to collectively handle 8% more daily visits without extending shifts.
  • Multispecialty clinic in the EU with 150 physicians adopted the solution to streamline operations across departments, resulting in consistent same-day note completion across departments and cutting clinician overtime by 25%. Standardized, higher-quality documentation also reduced documentation-related billing queries by 30%.
  • US-based community outpatient clinic with 15 physicians and ~120 daily visits adopted automated documentation to streamline workflows with a small administrative team. As a result, clinicians completed notes on the same day in 90%+ of cases and billing turnaround time decreased by 30%.

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The outcome

The developed AI tool supports a more efficient, patient-centered, and sustainable healthcare system, delivering the following benefits:

01

Time savings per patient interaction

02

Improved quality of medical histories

03

More engaging patient interactions

04

Higher billing accuracy
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