Method and system for generating a medical report and computer program product therefor

• US 10,586,018 B2
• Filed: 07/10/2014
• Issued: 03/10/2020
• Est. Priority Date: 03/29/2007
• Status: Active Grant

• Current Assignee: Microsoft Technology Licensing LLC (Microsoft Corporation)
• Original Assignee: Nuance Communications, Inc. (Microsoft Corporation)
• Inventors: Oez, Mehmet M.
• Primary Examiner(s): Pauls, John A
• Application Number:
  US14/328,411
• Publication Number:
  US 20140324477A1
• Time in Patent Office: 2,070 Days
• Field of Search: 705 2, 705 3, 600179, 600437
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G10L 15/26 Speech to text systems G10L15/08 takes precedence
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A method and a system for generating, with the assistance of a computer system (12), a medical report (18) suitable for automatic billing, where an electronic template (39) suited for a specific patient'"'"'s condition is selected out of a plurality of given electronic templates stored in storage means (15); personal data of the specific patient'"'"'s and previously stored in storage means (11) are automatically entered into the selected electronic template; and medical report text passages and instructions are entered into the selected template by dictating and using a speech recognition system (13); additionally, condition data are automatically entered on the basis of condition information as far as stored in storage means (7) into the selected template, and code data associated with these condition information are automatically embedded in the selected template; and when entering medical report text passages, at least one predetermined voice macro stored in the storage means (16) together with code data embedded therein is called in; the code data thus embedded in the medical report (18) being applicable when coding the medical report for automatic billing.

Claims

1. A method for generating a medical report, said method comprising:

receiving a selection of a template; and

generating the medical report for a patient at least in part by;

associating a preliminary set of medical billing codes with the medical report during generation of the medical report based, at least in part, on the selected template;

receiving speech for entering information into a portion of the medical report corresponding to at least one section in the selected template,

invoking a voice macro based, at least in part, on at least a portion of the received speech, wherein the voice macro has one or more first medical billing codes embedded in the voice macro, and wherein the voice macro, when invoked, instructs at least one processor to;

enter predetermined text associated with the voice macro into the portion of the medical report, and

update the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes to obtain an updated preliminary set of medical billing codes, wherein adding the one or more first medical billing codes to the preliminary set comprises automatically transferring the one or more first medical billing codes from the voice macro to the medical report by embedding the one or more first medical billing codes from the voice macro in the medical report,

populating at least one field of the selected template with data associated with the patient obtained from one or more sources other than the received speech, and

generating a processed set of medical billing codes that is at least a subset of the updated preliminary set of medical billing codes, wherein generating the processed set comprises;

for at least one medical billing code of the updated preliminary set of medical billing codes, generating a determination of whether to retain the at least one medical billing code in the medical report, wherein generating a determination of whether to retain the at least one medical billing code comprises;

determining whether the at least one medical billing code represents at least one ambiguity in the updated preliminary set of medical billing codes,

in response to a determination that the at least one medical billing code represents at least one ambiguity, determining whether the at least one ambiguity can be resolved based on the data obtained from the one or more sources other than the received speech, and

in response to a determination that the at least one ambiguity can be resolved, resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech.

2. The method of claim 1, wherein:

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on previously stored personal data associated with the patient.

3. The method of claim 1, wherein:

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on previously stored condition information associated with the patient.

4. The method of claim 1, wherein:

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on medical examination information entered into the selected template.

5. The method of claim 1, wherein:

the processed set of medical billing codes are temporary medical billing code data, and

the method further comprises transforming the temporary medical billing code data to final medical billing code data based, at least in part, on a prescribed coding system for automatic billing.

6. The method of claim 1, further comprising:

in response to identifying one or more medical images associated with the medical report;

obtaining from data associated with the one or more medical images, one or more second medical billing codes linked to the one or more medical images, and

associating the one or more second medical billing codes with the medical report.

7. The method of claim 1, wherein the one or more sources other than the received speech comprises a source from which personal data, previous condition information, or previous examination information associated with the patient is obtained.

8. The method of claim 1, wherein the one or more sources other than the received speech comprises a source from which initial consultation and/or diagnosis data associated with the patient is obtained.

9. The method of claim 1, wherein the one or more sources other than the received speech comprises a source from which medical image information associated with the patient is obtained.

10. The method of claim 1, wherein associating the preliminary set of medical billing codes with the medical report during generation of the medical report comprises:

adding one or more second medical billing codes to the medical report, wherein adding the one or more second medical billing codes comprises embedding one or more second medical billing codes corresponding to at least one source of the one or more sources other than the received speech into the medical report.

11. A system comprising:

at least one processor; and

at least one storage device storing;

a plurality of templates;

at least one voice macro comprising a first voice macro, wherein the first voice macro is associated with text and one or more first medical billing codes, and wherein the first voice macro, when invoked, causes the at least one processor to enter at least some of the text associated with the first voice macro in a portion of a medical report and to associate at least some of the one or more first medical billing codes from the first voice macro with the medical report as hidden tags; and

executable instructions that, when executed by the at least one processor, cause the at least one processor to;

receive a selection of a template from among the plurality of templates stored by the at least one storage device;

associate a preliminary set of medical billing codes with the medical report for a patient during generation of the medical report based, at least in part, on the selected template;

receive speech for entering information into the portion of the medical report corresponding to at least one section in the selected template;

invoke the first voice macro based, at least in part, on at least a portion of the received speech to cause the at least one processor to enter the text associated with the first voice macro into the portion of the medical report and to associate the one or more first medical billing codes from the first voice macro with the medical report, wherein associating the one or more first medical billing codes comprises updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes in the medical report to obtain an updated preliminary set of medical billing codes;

populate at least one field of the selected template with data associated with the patient obtained from one or more sources other than the received speech; and

generate a processed set of medical billing codes that is at least a subset of the updated preliminary set of medical billing codes, wherein generating the processed set comprises;

for at least one medical billing code of the updated preliminary set of medical billing codes, generating a determination of whether to retain the at least one medical billing code associated with the medical report, wherein generating a determination of whether to retain the at least one medical billing code comprises;

 

determining whether the at least one medical billing code represents at least one ambiguity in the updated preliminary set of medical billing codes,

 

in response to a determination that the at least one medical billing code represents at least one ambiguity, determining whether the at least one ambiguity can be resolved based on the data obtained from the one or more sources other than the received speech, and

in response to a determination that the at least one ambiguity can be resolved, resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech.

12. The system of claim 11, wherein:

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on previously-stored personal data associated with the patient.

13. The system of claim 11, wherein:

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on previously-stored condition information associated with the patient.

14. The system of claim 11, wherein:

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on medical examination information entered into the selected template.

15. A non-transitory computer-readable storage medium encoded with a plurality of computer-executable instructions that, when executed by at least one processor, cause the at least one processor to perform a method comprising:

associating a preliminary set of medical billing codes with a medical report for a patient during generation of the medical report;

receiving speech for entering information into a portion of the medical report,

invoking a voice macro based, at least in part, on at least a portion of the received speech, wherein the voice macro is associated with text and one or more first medical billing codes and wherein the voice macro, when executed by at least one processor, causes the at least one processor to;

enter at least some of the text associated with the voice macro into the portion of the medical report, and

associate at least some of the one or more first medical billing codes of the voice macro with the medical report, wherein associating at least some of the one or more first medical billing codes comprises updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes in the medical report to obtain an updated preliminary set of medical billing codes,

populating at least one field of the medical report with data associated with the patient obtained from one or more sources other than the received speech, and

generating a processed set of medical billing codes that is at least a subset of the updated preliminary set of medical billing codes, wherein generating the processed set comprises;

for at least one medical billing code of the updated preliminary set of medical billing codes, generating a determination of whether to retain the at least one medical billing code associated with the medical report, wherein generating a determination of whether to retain the at least one medical billing code comprises;

determining whether the at least one medical billing code represents at least one ambiguity in the updated preliminary set of medical billing codes,

in response to a determination that the at least one medical billing code represents at least one ambiguity, determining whether the at least one ambiguity can be resolved based on the data obtained from the one or more sources other than the received speech, and

in response to a determination that the at least one ambiguity can be resolved, resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech.

16. The non-transitory computer-readable storage medium of claim 15, wherein

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on previously-stored personal data associated with the patient and/or on previously stored condition information associated with the patient.

17. The non-transitory computer-readable storage medium of claim 15, wherein

resolving the at least one ambiguity using the data obtained from the one or more sources other than the received speech comprises resolving the at least one ambiguity based, at least in part, on medical examination information entered into the medical report.

18. The non-transitory computer-readable storage medium of claim 15, wherein adding the one or more first medical billing codes to the preliminary set of medical billing codes comprises embedding the one or more first medical billing codes from the voice macro in the medical report.

19. The non-transitory computer-readable storage medium of claim 18, wherein embedding the one or more first medical billing codes from the voice macro in the medical report comprises embedding the one or more first medical billing codes in the medical report as hidden tags.

20. The non-transitory computer-readable storage medium of claim 19, wherein embedding the one or more first medical billing codes in the medical report as hidden tags comprises embedding the one or more first medical billing codes such that the one or more first medical billing codes embedded in the medical report are not visible when the medical report is presented to a clinician in a display.