03 / Diagnoss

Designing an AI-Powered EHR Assistant for Clinical Documentation and Coding

Diagnoss was designed as an EHR-embedded assistant that helps healthcare providers analyze clinical documentation, identify coding opportunities, and improve documentation without forcing them to leave the system they already use.

Role

  • UX Designer

Timeline

  • 2019 — 2020

Platforms

  • EHR-Embedded Web Application
  • AI Assistant

Focus Areas

  • Healthcare UX
  • AI-Assisted Workflows
  • Clinical Documentation
  • Medical Coding
  • Information Architecture
  • Workflow Optimization
  • User-Centered Design

01

An assistant inside the workflow.

Overview

Diagnoss is an AI-assisted healthcare workflow designed to help providers document diagnoses, identify appropriate billing codes, and improve clinical documentation directly within their existing EHR environment.

The product evolved from a standalone healthcare application concept into a lightweight EHR-embedded assistant. Rather than asking providers to open another application, navigate between systems, or manually transfer information, Diagnoss brings intelligence directly into the clinical workflow.

The experience analyzes the patient's clinical documentation and provides contextual assistance while the provider continues working inside the EHR.

This evolution shifted the UX challenge from designing an application to designing an intelligent layer within an existing application.

Three primary capabilities

  • 01Connecting directly to the existing EHR context
  • 02Analyzing clinical notes and identifying documentation opportunities
  • 03Assisting with diagnosis and billing-code decisions

02

Streamlining medical coding and note-taking without losing accuracy.

The Challenge

Medical documentation and coding are two of the most time-consuming parts of a provider's day. Notes must be complete, codes must be accurate, and both must align with the clinical record. Yet most providers still move between the EHR, coding references, and external tools to close the gap, slowing the encounter and increasing the risk of missing revenue or documentation.

Not this question

"How do we build a faster documentation tool?"

The actual question

"How do we streamline and optimize coding and note-taking inside the provider's existing workflow?"

The design needed to

  • Reduce time spent on documentation and coding
  • Surface accurate code suggestions from clinical notes
  • Keep the provider inside the EHR
  • Flag missing or incomplete documentation
  • Make recommendations clear and reviewable
  • Preserve provider control over final decisions
  • Improve coding accuracy without adding manual work
  • Support the natural flow of the patient encounter
  • Work within existing EHR constraints

03

Discovery, users, and workflow seams.

Research & Discovery

Discovery combined conversations with clinical and business stakeholders, close reading of real documentation workflows, and analysis of where existing tools created friction. The central research question shaped every decision that followed:

“Where can intelligent assistance be introduced without interrupting the provider's existing workflow?”
#ActivityWhat it informed
01
Stakeholder interviews
Aligning clinical, product, and engineering perspectives on where assistance would be welcome and where it would intrude.
02
Workflow analysis
Mapping how providers move through chart review, documentation, coding, and sign-off inside the EHR.
03
Clinical documentation analysis
Reading real note structures to understand what information is present, implied, or missing.
04
User-centered design
Framing every feature around the provider's task rather than the model's capability.
05
Usability research
Iterative evaluations of the sidebar states, recommendation cards, and review actions.
06
Requirements gathering
Defining scope, compliance considerations, and EHR integration constraints.
07
Competitive / product analysis
Reviewing adjacent documentation and coding tools to identify patterns worth adopting or avoiding.
08
Cross-functional collaboration
Working closely with engineering and clinical stakeholders through design and implementation.

Primary user

Healthcare Providers

Needs

  • Document diagnoses efficiently
  • Select appropriate billing codes
  • Complete clinical notes
  • Identify missing documentation
  • Understand coding implications
  • Maintain focus on the patient encounter

Pain points

  • Documentation takes time
  • Coding decisions can be complex
  • Important information can be missed
  • Switching between applications creates friction
  • Providers must balance clinical care with administrative requirements

Secondary stakeholders

Healthcare Organizations

Needs

  • More complete documentation
  • Appropriate coding
  • Better workflow efficiency
  • Improved revenue capture
  • Consistent documentation practices

Pain points

  • Incomplete documentation leads to revenue leakage
  • Inconsistent coding increases audit and compliance risk
  • Administrative overhead reduces provider productivity
  • Existing tools fail to show measurable ROI
  • EHR implementation fatigue limits adoption of new systems

04

From findings to principle.

Key Findings

01

Information was fragmented

Providers already worked across complex systems and workflows.

02

Context switching created friction

Opening another application required providers to leave their current clinical workflow.

03

AI recommendations needed context

Recommendations become more useful when they understand the patient, encounter, and clinical note being reviewed.

04

Providers needed control and transparency

AI recommendations needed to be understandable, explainable, and reviewable rather than presented as unexplained decisions.

“Don't make providers go to the AI.”

“Bring the AI into the workflow.”

The core product decision was to transform Diagnoss from a standalone destination into an embedded assistant. The EHR remains the primary workspace.

Diagnoss becomes a contextual intelligence layer that can be opened when needed, analyze information already present, and provide assistance without forcing the provider to leave the current workflow.

Old model — standalone application

  1. 01EHR
  2. 02Leave EHR
  3. 03Open Diagnoss
  4. 04Find patient
  5. 05Transfer information
  6. 06Analyze
  7. 07Return to EHR

New model — embedded sidebar

  1. 01EHR + Diagnoss sidebar
  2. 02Patient context automatically synchronized
  3. 03Analyze documentation
  4. 04Review recommendations
  5. 05Provider decision

Artifact

10

Before / after context-switching workflow

Seven steps across two systems collapse into a single continuous workflow inside the EHR.

05

An intelligence layer on top of the record.

Product Architecture

Existing EHR

The system of record

  • Patient context
  • Clinical notes
  • Medications
  • Vitals
  • Problem list
  • Labs
  • Billing

Diagnoss embedded sidebar

  1. 01Connect
  2. 02Analyze
  3. 03Assist
  4. 04Provider review
  5. 05Provider decision

Diagnoss enhances the existing EHR rather than replacing it. Every input it uses already lives in the record; every output returns to the provider as a reviewable recommendation.

Artifact

09

EHR + Diagnoss architecture diagram

How the sidebar reads from the active EHR context and returns recommendations into the provider's review.

07

Connect

Trust before assistance.

Diagnoss Connect state showing a secure session, detected MERIDIAN CareChart EHR, patient context, and last sync timestamp.
Secure session, detected EHR, and synchronized patient context shown before any recommendation appears.

State contents

  • Secure session status
  • EHR name detected
  • Patient context synchronized
  • Patient name
  • MRN
  • Last synchronization timestamp
  • Connection status

UX rationale

Before providing recommendations, the provider needs confidence that Diagnoss is connected to the correct EHR and patient context. This creates trust before AI assistance begins. Removing manual patient lookup reduces unnecessary steps and helps prevent workflow disruption.

08

Analyze

Show the reading, not just the result.

State contents

  • Reading note — progress state
  • Completed analysis state
  • Note completeness indicator
  • Detected diagnoses
  • Procedures
  • Medications
  • Relevant documentation
  • Source snippets

UX rationale

Diagnoss analyzes the clinical note in context rather than treating the provider's input as an isolated text prompt. The system should make its analysis visible rather than presenting recommendations as unexplained AI output.

Diagnoss Analyze state showing note analysis progress, 92% completeness, 7 entities, 4 gaps, and detected clinical findings.
Progress while reading the note, then a completeness indicator with detected clinical entities and source snippets.

Detected entities

  • Type 2 diabetes mellitus
  • Hypertension
  • Metformin 500 mg
  • A1c 8.2%
  • Office visit, established patient
  • Foot exam

09

Assist

Recommendations with the reasoning attached.

Diagnoss Assist state showing E/M level feedback, achievable code suggestions, and CDI recommendations with accept or dismiss actions.
Ranked diagnosis and procedure codes with documented evidence and one-tap EHR actions.
Diagnoss ICD-10 and CPT predictions showing ranked codes, confidence percentages, and Send to EHR buttons.
ICD-10 and CPT predictions presented in a consistent card hierarchy.

10

The public-facing Diagnoss website.

Marketing Site

Alongside the EHR assistant, Diagnoss needed a marketing site that could translate complex clinical AI capabilities into a clear, credible value proposition for providers, administrators, and health systems.

Diagnoss marketing homepage showing the hero message, value proposition, and product overview sections.

Outcome-first messaging

Revenue, accuracy, and provider happiness lead the story rather than technology claims.

Single primary CTA

A free coding assessment is repeated across the page so the next step is always obvious.

Healthcare credibility

Clinical credibility is established through team credentials, investors, and a calm, professional visual tone.

11

What the embedded model changed.

Outcomes

01

Reduced context switching

Diagnoss brings assistance directly into the provider's existing environment.

02

Contextual intelligence

The assistant uses the active patient and clinical documentation as context.

03

More actionable AI

Recommendations include supporting information and rationale rather than unexplained outputs.

04

Provider control

Providers remain responsible for reviewing and accepting recommendations.

05

Workflow efficiency

The experience reduces unnecessary navigation and manual information transfer.

06

Scalable AI architecture

The embedded-sidebar approach creates a foundation for expanding AI assistance across additional EHR workflows.

12

Where the AI should exist.

Reflection

This project changed how I think about AI product design.

“The best AI experiences don't necessarily ask users to interact with AI. They make the user's existing workflow more intelligent.”