WakeMed Health Gains $10M With AI Documentation And Clinical Insights System

WakeMed Health & Hospitals in Raleigh, North Carolina, faced a challenge with its electronic health record (EHR) system, which is essential for both revenue and quality scoring. Improving documentation accuracy required more physician time in the EHR, contributing to frustration and burnout. Clinicians often spend up to two hours on data entry per hour of patient contact, and inadequate documentation time increases burnout risk. WakeMed needed better documentation to support financial and quality outcomes but wanted to avoid adding to physician workload.

Dr. David Kirk, chief clinical integration officer, explained that clinicians feel burdened by documentation tasks that detract from patient care. Recognizing the importance of accurate documentation for revenue and quality, yet aware of clinician exhaustion, WakeMed explored AI technology to improve charts while reducing clinician effort.

WakeMed took a three-part approach focusing on data, people, and technology. They identified hospitalists as the main target and introduced an AI-powered clinical insights platform from Regard, providing training and support. The AI reviews a patient’s entire electronic record to suggest diagnoses and evidence, helping physicians document more efficiently.

This AI integrates with the EHR to analyze charts, surface insights, summarize records, and enhance diagnoses with supporting evidence that would otherwise take significant time. This streamlined documentation improved accuracy, coding, and revenue capture while easing physician burnout. For example, if a physician diagnoses sepsis, the AI pulls detailed evidence to strengthen documentation for proper reimbursement and care.

Currently used primarily by hospitalists, the platform lets clinicians finalize information faster, freeing time for clinical decisions. WakeMed plans to expand its use to other departments and eventually all providers.

Early results show $9.3 million recovered in claims that might have been denied, plus $871,000 in new Medicare revenue by better reflecting patient complexity. There was also a 3% improvement in illness severity recognition and a 3.6% increase in coding capture rates, boosting quality scores and hospital ratings.

Dr. Kirk notes that cultural resistance, not technology, is the main barrier to AI adoption. Physicians often see charts as storytelling tools and may distrust tools focused on coding. However, as AI supports clinicians’ documentation styles and improves quality scores, adoption is increasing. Kirk advises involving physicians early, demonstrating clinical benefits, and emphasizing that AI supports—not replaces—care, ensuring accurate documentation for better patient outcomes and continuity of care.