Case studies / Healthcare
Case studyClinical documentation support with privacy designed in
A hospital group gave clinical administrators an assistant that drafts referral summaries and letters inside its secure environment, with clinicians signing off every item.
Overview
A not-for-profit hospital group in the Benelux region operating five hospitals and a network of outpatient clinics, subject to strict national health-data rules and European data protection law.
Scale. Around 9,000 incoming referrals and 15,000 outgoing clinical letters a month across more than thirty departments.
The challenge
Referrals arrived as long, inconsistent documents: letters from family doctors, discharge notes from other hospitals, test results and scanned forms. Clinical administrators read each one and wrote a short summary so the consultant could triage it. A complicated referral could take forty minutes.
Outgoing letters were a second burden. Clinicians dictated or typed notes after clinics, and administrators turned them into letters for patients and referring doctors. Backlogs of a week or more were common in busy specialties, and some letters left with inconsistent structure or missing results.
Any automation touched the most sensitive data the group held. The privacy officer and the clinical-safety lead were clear from the first meeting: nothing could leave the secure environment, nobody could see records they were not entitled to, and no text could reach a patient file without a clinician reading it first.
The solution
When a referral arrives, the administrator opens it in the patient record system and asks the assistant for a summary. The assistant reads the referral and the relevant parts of the record the administrator is permitted to see, then drafts a structured summary: reason for referral, relevant history, current medication, results and urgency indicators, each with a link back to its source document.
For outgoing letters, the assistant drafts from the clinician's notes using approved templates for each specialty and audience. A letter to a referring doctor carries different detail from one to a patient. The clinician reviews, edits and signs, and only then is the letter filed and sent through secure messaging.
Nothing is filed automatically. The assistant's drafts are clearly marked as drafts until signed. Access controls are inherited, not copied, so a change in someone's permissions takes effect immediately. A monitoring view shows usage by department, edit rates, turnaround times and any flagged content.
The engagement
- Nine months
- Six specialists, working with the group's privacy, clinical-safety and IT teams
- Governance requirements, secure architecture, summary and letter drafting, record-level permissions, clinician review workflow, pilot and staged extension with monitoring.
Integrations
- Patient record system
- Identity and access service
- Clinical document store
- Secure messaging
- Audit log
How we delivered it
- 01
Agree privacy and safety requirements first
Seven weeks
Before any design work, we sat with the privacy, clinical-safety and information-governance teams and wrote down the rules: where data could be processed, who could see what, what had to be logged, and how errors would be reported. These requirements became acceptance criteria for every later phase.
- 02
Build inside the secure environment
Ten weeks
The assistant was built entirely within the group's own hosting, using record-level permissions inherited from the patient record system. It could only read records the requesting user was already allowed to open, and every read and draft was written to the audit log.
- 03
Pilot with one department
Eight weeks
The cardiology outpatient service volunteered. Administrators used the assistant for referral summaries and clinic letters, and clinicians reviewed every item. We tracked time taken, edits made and any content the clinicians judged inaccurate or incomplete.
- 04
Extend with continuing monitoring
Twelve weeks
Departments joined in small groups after a short readiness check and training. Quality sampling, edit rates and access logs were reviewed monthly by a joint panel of clinicians, governance staff and our team.
Results
- Less administrative time on referral summaries and letters
- Clinicians signed off every item before filing
- Privacy controls evidenced for audit and inspection
- Shorter letter backlogs in live departments
Administrators in live departments spend considerably less time on each referral summary, and letter backlogs in the pilot specialty fell from over a week to two or three days. The time saved has gone into chasing missing results and booking patients, work that had been squeezed out.
Every summary and letter was signed by a clinician. Edit rates fell over the first months as templates were refined, but the review step stayed, by design. Clinicians reported that structured summaries with source links made triage quicker and more consistent.
When the national health-data regulator carried out a routine inspection, the group could show exactly who had accessed which records through the assistant, when and why. The privacy controls were evidenced, not asserted.
Governance was in the room from the first day. That is why we could say yes to extending it, rather than spending months trying to retrofit controls.
What made the difference
Privacy rules were designed in, not added later. Writing the governance requirements before any design work meant the system passed review because it had been built to pass it.
