Document AI

Medical Records Extraction

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Overview

A multi-specialty clinic receiving hundreds of referral documents daily via fax and email was spending enormous staff hours manually entering patient data into their EHR. Documents came in every format imaginable — handwritten notes, typed reports, lab printouts, and imaging reports. We built a HIPAA-compliant AI pipeline that processes any medical document, extracts structured data, maps it to the correct EHR fields, and flags anything requiring clinical review.

The Challenge

Medical documents contain sensitive PHI requiring HIPAA compliance at every stage. Handwritten physician notes are notoriously difficult to OCR. Medical terminology and abbreviations are domain-specific. The system needed to distinguish between active medications and discontinued ones, current diagnoses and historical ones, and map everything to standardized medical codes.

Our Approach

We deployed the entire pipeline on HIPAA-compliant infrastructure with encryption at rest and in transit. A specialized medical OCR model handles handwritten notes. The extraction layer uses a medical LLM fine-tuned on clinical documents to understand context — distinguishing 'patient was on metformin' (past) from 'continue metformin' (current). All extractions map to ICD-10 and CPT codes automatically.

Key Features

  • HIPAA-compliant end-to-end processing
  • Handwritten note recognition
  • ICD-10 and CPT code mapping
  • Medication reconciliation
  • Lab result extraction and trending
  • EHR auto-population with clinical review queue
  • Audit trail for compliance

Results

90%
Data entry time reduction
98.5%
Extraction accuracy for typed documents
94%
Handwriting recognition accuracy
5 staff
Redeployed to patient care

Try It Yourself

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Client Feedback

Our intake team used to spend their entire day on data entry. Now they greet patients and the AI handles the paperwork.

Category

Document AI

Tech Stack

Azure AI Document Intelligence Med-PaLM Python HIPAA-Compliant Azure HL7 FHIR Epic EHR Integration

Quick Stats

90% Data entry time reduction
98.5% Extraction accuracy for typed documents
94% Handwriting recognition accuracy
5 staff Redeployed to patient care

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