Dyke Ferber, Lars Hilgers, Christiane Höper, Benedict Kinny‐Köster, Jan‐Niklas Eckardt, Katharina Egger‐Heidrich, Marius Bill, Martin Schneider, Jan Clusmann, Lejla Kadric, Marcel Oehme, Maximilian Mayrhofer‐Schmid, Alexander Oeser, Georg Wölflein, Isabella C. Wiest, Jan Moritz Middeke, A J. Iafrate, Daniel Truhn, Dirk Jaeger, Jakob Nikolas Kather
. However, building physician copilots will require models that operate within the electronic health record (EHR), with governed access to patient data and the ability to initiate permitted EHR actions within defined safety constraints. Yet it remains unproven whether such a system can manage patient cases with physician-level performance. Here we show that MIRA (Medical Intelligence for Reasoning and Action), an autonomous artificial intelligence agent operating in a sandboxed EHR environment, can navigate a large clinical action space to obtain patient histories; order and interpret laboratory, imaging and microbiology tests; generate differential diagnoses; and formulate treatment plans such as prescribing medications, scheduling surgical procedures and planning admissions. In simulations on real patient cases spanning multiple diagnoses, MIRA outperformed physicians in diagnostic accuracy and made guideline-concordant, medication-safe and appropriate admission decisions. Compared with previous LLM applications that addressed isolated subtasks or provided free-text advice, these results suggest that an EHR-integrated artificial intelligence agent can turn clinical intent into structured, actionable EHR operations, possibly making it a more effective decision-support partner for physicians. Further work is needed to establish generalization, safety and governance through prospective, real-world studies.