Duplication detection in clinical documentation to update a clinician

• US 10,007,407 B2
• Filed: 12/31/2014
• Issued: 06/26/2018
• Est. Priority Date: 11/03/2014
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Gifford, Thomas C., Cole, Chad A., Tyler, J D, Venkat, Savitha, Ash, Michael A., McCord, Tonja, Garg, Anubha, Crooks, Steven S., Finn, Christopher S., Kolm, Margaret C., O'Larte, David J., McCallie, Jr., David P.
• Primary Examiner(s): Chng, Joy
• Application Number:
  US14/587,853
• Publication Number:
  US 20160125144A1
• Time in Patent Office: 1,273 Days
• Field of Search: 705 2- 3
• CPC Class Codes: G06F 16/1748 De-duplication implemented within the file system, e.g. based on file segments de-duplication techniques in storage systems for the management of data blocks G06F3/0641
• CPC Class Codes: G06F 16/2358 Change logging, detection, and notification replication G06F16/27
• CPC Class Codes: G06F 16/24556 Aggregation; Duplicate elimination
• CPC Class Codes: G06F 16/24578 using ranking
• CPC Class Codes: G06F 16/2477 Temporal data queries
• CPC Class Codes: G06F 16/248 Presentation of query results
• CPC Class Codes: G06F 16/335 Filtering based on additional data, e.g. user or group profiles filtering in web context G06F16/9535, G06F16/9536
• CPC Class Codes: G06F 16/93 Document management systems
• CPC Class Codes: G06F 16/951 Indexing; Web crawling techniques
• CPC Class Codes: G06F 3/0484 for the control of specific functions or operations, e.g. selecting or manipulating an object, an image or a displayed text element, setting a parameter value or selecting a range
• CPC Class Codes: G06F 3/04842 Selection of displayed objects or displayed text elements G06F3/0482 takes precedence
• CPC Class Codes: G06F 40/151 Transformation
• CPC Class Codes: G06F 40/166 Editing, e.g. inserting or deleting
• CPC Class Codes: G06F 40/194 Calculation of difference between files
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 70/00 ICT specially adapted for the handling or processing of medical references

Abstract

Methods, systems, and computer-readable media are provided to detect incremental changes in clinical documents associated with a patient. A user selection is received indicating that a user wants to compare two or more clinical documents that are associated with the patient or authored by the same clinician, enabling the user to become up-to-date on the patient'"'"'s care. A first clinical document and a second clinical document are identified. For the first clinical document and the second clinical document, differences are algorithmically determined. The first clinical document is transformed into a new representation of the first clinical document. Further, the second clinical document is transformed into a new representation of the second clinical document. One or more of the new representations of the first and the second clinical documents are displayed, assisting the user to quickly find and understand the differences between the documents.

Claims

1. One or more non-transitory computer-readable media having computer-executable instructions embodied thereon that, when executed by a computing device, perform a method of detecting incremental changes in clinical documents, the method comprising:

receiving a user selection indicating that a user wants to compare two or more clinical documents that are associated with the patient or are authored by a same clinician, enabling the user to become up-to-date on the patient'"'"'s care;

identifying a first clinical document and a second clinical document that are to be compared, the first clinical document created prior to the second clinical document and identified from a plurality of stored clinical documents, wherein identifying the first clinical document from the plurality of stored clinical documents comprises limiting a search of the plurality of stored documents to a selection of clinical documents comprising a subset of the plurality of stored clinical documents, and wherein the search is limited based on one or more of document type, date, location, encounter, subject, or author;

for the first clinical document and the second clinical document, algorithmically determining differences between the first clinical document and the second clinical document;

transforming the first clinical document into a new representation of the first clinical document, the new representation of the first clinical document comprising an indication of data in the first clinical document that is not in the second clinical document;

transforming the second clinical document into a new representation of the second clinical document, the new representation of the second clinical document comprising an indication of data in the second clinical document that is not in the first clinical document;

utilizing a trained algorithm to determine inappropriate documentation between the first clinical document and the second clinical document based on a statistical probability that information provided in the second clinical document should differ from the first clinical document; and

displaying one or more of the new representation of the first clinical document and the new representation of the second clinical document on a single user interface, and indicating the inappropriate documentation and a risk of the inappropriate documentation.

2. The media of claim 1, further comprising determining which portions of the first clinical document and the second clinical document to compare, wherein the portions that are compared comprise one or more elements that are statistically unlikely to be included in both the first clinical document and the second clinical document.

3. The media of claim 1, further comprising receiving a user selection indicating that a user wants to compare the second clinical document with a third clinical document.

4. The media of claim 3, further comprising:

algorithmically determining changes from the second clinical document to the third clinical document, wherein the third clinical document was selected for comparison by one of the user or the computing device;

transforming the second clinical document into a second new representation of the second clinical document, the second new representation of the second clinical document comprising an indication of data in the second clinical document that is not in the third clinical document;

transforming the third clinical document into a new representation of the third clinical document, the new representation of the third clinical document comprising an indication of data in the third clinical document that is not in the second clinical document; and

displaying one or more of the second new representation of the second clinical document and the new representation of the third clinical document on a single user interface.

5. The media of claim 4, wherein the first clinical document was created at a first time corresponding to when the patient was treated, the second clinical document was created at a second time corresponding to when the patient was treated, and the third clinical document was created at a third time corresponding to when the patient was treated.

6. The media of claim 1, wherein the first clinical document and the second clinical document were created at times corresponding to consecutive patient visits or treatments.

7. The media of claim 1, wherein the inappropriate documentation between the first clinical document and the second clinical document is an inappropriate similarity between the first clinical document and the second clinical document.

8. One or more non-transitory computer-readable media having computer-executable instructions embodied thereon that, when executed by a computing device, perform a method of detecting incremental changes in clinical documents, the method comprising:

receiving a user selection indicating that a user wants to compare two or more clinical documents that are associated with the patient or are authored by a same clinician to enable the user to become up-to-date on the patient'"'"'s care;

based on receiving the user selection, determining one or more portions of at least a first clinical document and a second clinical document that are to be compared, wherein the one or more portions are determined insensitive to the arrangement of text in the first clinical document and the second clinical document based on normalizing the first clinical document and the second clinical document and determining a beginning and an ending of each section in the first clinical document and the second clinical document;

for the first clinical document and the second clinical document, algorithmically determining differences between the one or more portions of the first clinical document and the second clinical document;

utilizing a trained algorithm to determine inappropriate documentation between the first clinical document and the second clinical document by identifying textual information in the first clinical document and the second clinical document having a statistical probability that the textual information should differ, wherein identifying the textual information is based on the textual information having a temporal element, a charge-based element, or a clinical procedure phrase;

transforming one or both of the first clinical document and the second clinical document into one or more new clinical document representations, the one or more new clinical document representations comprising at least an indication of the textual information having the statistical probability that the textual information should differ;

displaying on a single user interface;

(A) the one or more new clinical document representations, and

(B) one or more selectable options that allow the user to compare the first clinical document or the second clinical document with other clinical documents associated with the patient; and

providing an indication of a risk of the inappropriate documentation.

9. The media of claim 8, further comprising identifying the second clinical document to which the first clinical document is to be compared.

10. The media of claim 8, further comprising displaying the one or more new clinical document representations on a single user interface.

11. The media of claim 8, wherein the first clinical document was created prior to the second clinical document.

12. The media of claim 8, wherein the second clinical document was created prior to the first clinical document.

13. The media of claim 8, wherein the first clinical document and the second clinical document were created on consecutive patient visits or treatments.

14. The media of claim 8, wherein the first clinical document and the second clinical document were authored by different clinicians.

15. The media of claim 8, wherein the one or more new clinical document representations comprise a new representation of the first clinical document and a new representation of the second clinical document, wherein the new representation of the first clinical document and the new representation of the second clinical document are displayed on a single user interface.

16. The media of claim 8, wherein the one or more selectable options allow the user to compare the second clinical document to at least a third clinical document, and wherein the second clinical document was created prior to the third clinical document.

17. A system for detecting incremental changes in clinical documents associated, the system comprising:

one or more processors; and

one or more non-transitory computer storage media storing computer-useable instructions that, when used by the one or more processors, cause the one or more processors to;

display, on a user interface, indications of differences between a first clinical document and a second clinical document that are associated with the patient or are authored by a same clinician,

receive a user selection of a selectable option on the user interface, the user selection of the selectable option indicating that a user wants to compare the second clinical document to a third clinical document,

algorithmically determine data in the second clinical document that is different than the third clinical document, and data in the third clinical document that is different than the second clinical document,

utilize a trained algorithm to determine inappropriate documentation between the second clinical document and the third clinical document by identifying textual information in the second clinical document and the third clinical document having a statistical probability that the textual information should differ, wherein identifying the textual information is based on the textual information having a temporal element, a charge-based element, or a clinical procedure phrase,

transform the second clinical document into a new representation of the second clinical document, the new representation of the second clinical document comprising an indication of the data in the second clinical document that is not in the third clinical document,

transform the third clinical document into a new representation of the third clinical document, the new representation of the third clinical document comprising an indication of the data in the third clinical document that is not in the second clinical document, and

display one or more of the new representation of the second clinical document and the new representation of the third clinical document on the user interface, and indicate a risk of the inappropriate documentation.

18. The system of claim 17, wherein the second clinical document and the third clinical document are associated with a same patient or are authored by a same clinician.

19. The system of claim 17, wherein the one or more processors further receive the user selection of the selectable option on the user interface, the user selection of the selectable option indicating that the user wants to compare the third clinical document to a fourth clinical document associated with the patient.

20. The system of claim 19, wherein the one or more processors further:

algorithmically determine data in the third clinical document that is different than the fourth clinical document, and data in the fourth clinical document that is different than the third clinical document,

transform the third clinical document into a second new representation of the third clinical document, the second new representation of the third clinical document comprising an indication of the data in the third clinical document that is not in the fourth clinical document,

transform the fourth clinical document into a new representation of the fourth clinical document, the new representation of the fourth clinical document comprising an indication of the data in the fourth clinical document that is not in the third clinical document, and

display one or more of the second new representation of the third clinical document and the new representation of the fourth clinical document on the user interface.