Patient encounter electronic medical record system, method, and computer product

• US 20040128323A1
• Filed: 12/17/2003
• Published: 07/01/2004
• Est. Priority Date: 03/28/2001
• Status: Active Grant

• Current Assignee: Mark Madden, Thomas W. Walker
• Original Assignee: Mark Madden, Thomas W. Walker
• Inventors: Madden, Mark, Walker, Thomas M.
• Granted Patent: US 7,461,079 B2
• Time in Patent Office: Days
• US Class Current: 707/104.1
• CPC Class Codes: G06Q 20/204 comprising interface for record bearing medium or carrier for electronic funds transfer or payment credit
• 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: Y10S 707/99931 Database or file accessing
• CPC Class Codes: Y10S 707/99943 Generating database or data structure, e.g. via user interface
• CPC Class Codes: Y10S 707/99945 Object-oriented database structure processing

Abstract

A patient encounter electronic medical record system, method, and computer product includes pre-populated, diagnosis specific templates, selective, specialty-specific master databases, and anatomic specific databases and templates to achieve comprehensive, accurate and compliant medical documentation that captures patient data concurrently with the clinical patient encounter session. The system is enabled for a distributed computing environment including graphical user interfaces and voice, text, and digital image and x-ray input.

Claims

1. A patient encounter electronic medical record apparatus comprising:

a processor;

an input interface configured to receive data input by a physician and an output interface coupled to said processor;

a memory; and

a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a pre-determined diagnosis;

wherein said user interface is configured to receive an input by said physician after said physician has made a diagnosis to select a subset of said diagnosis specific pre-populated templates that correspond with the diagnosis made by the physician, and said processor is configured to produce an electronic medical record from said subset of diagnosis specific pre-populated templates, said diagnosis specific pre-populated templates being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesics setting, and a therapy setting.

2. The apparatus of claim 1, wherein:

said input interface includes a graphical user interface, and

said output interface includes a graphical user interface

3. The apparatus of claim 1, wherein said diagnosis specific pre-populated templates include at least one of specialty-specific templates and primary care templates.

4. The apparatus of claim 1, wherein said processor is a component of a distributed computing system.

5. The apparatus of claim 1, wherein said plurality of diagnosis specific pre-populated templates are configured for at least one of a drilldown logic and a rollup logic.

6. The apparatus of claim 1, wherein said plurality of diagnosis specific pre-populated templates include graphics modulated schematics.

7. The apparatus of claim 1, wherein said diagnosis specific pre-populated templates are derived from at least one of a selective specialty specific database and an anatomic specific database.

8. The apparatus of claim 1, wherein said diagnosis specific pre-populated templates are end-user modifiable.

9. The apparatus of claim 1, wherein said input interface is configured to convert voice input into text via a speech recognition mechanism.

10. The apparatus of claim 1, wherein said input interface is configured to receive data of at least one of a digital image input, a digital x-ray input, and a wireless device input.

11. The apparatus of claim 1, wherein said plurality of diagnosis specific pre-populated templates are configured for at least one of E/M documentation, x-rays, diagnostic studies, prescriptions, and reports.

12. The apparatus of claim 4, wherein said distributed computing environment comprises at least one of a payment system and an audit system.

13. The apparatus of claim 4, wherein said distributed computing environment comprises at least one of a Wide Area Network, a Local Area Network, and a Wireless Network.

14. A patient encounter electronic medical record apparatus comprising:

a processor;

inputting means for receiving data input by a physician and outputting means for outputting data, said inputting means and said outputting means coupled to said processor;

memory means for storing data; and

a plurality of diagnosis specific pre-populated template means for structuring data stored in said memory means and accessible by said processor means, default entries in said diagnosis specific pre-populated template means being changeable to alternate values by said physician, said default entries being associated with a predetermined diagnosis;

wherein said inputting means is configured to receive an input by said physician after said physician has made a diagnosis to select a subset of said diagnosis specific pre-populated template means that correspond with a the diagnosis made by the physician, and said processor produces an electronic medical record from said plurality of diagnosis specific pre-populated template means, said diagnosis specific pre-populated template means being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesics setting, and a therapy setting.

15. The apparatus of claim 14, wherein:

said inputting means includes a graphical interface; and

said outputting means includes a graphical interface

16. The apparatus of claim 14, wherein said diagnosis specific pre-populated template means includes at least one of specialty-specific templates and primary care templates.

17. The apparatus of claim 14, wherein said processing means is a component of a distributed computing means.

18. The apparatus of claim 14, wherein said plurality of diagnosis specific pre-populated template means are configured for at least one of a drilldown logic and a rollup logic.

19. The apparatus of claim 14, wherein said plurality of diagnosis specific pre-populated template means includes graphics modulated schematic means.

20. The apparatus of claim 14, wherein said diagnosis specific pre-populated template means are derived from at least one of a selective specialty specific database and an anatomic specific database.

21. The apparatus of claim 14, wherein said diagnosis specific pre-populated template means is end-user modifiable.

22. The apparatus of claim 14, wherein said inputting means is configured for receiving voice input and means for converting speech into text.

23. The apparatus of claim 14, wherein said inputting means is configured for receiving at least one of a digital image, a digital x-ray input, and data from a wireless device.

24. The apparatus of claim 14, wherein said plurality of diagnosis specific pre-populated template means are configured for receiving at least one data from E/M documentation, an x-ray record, a diagnostic study, a prescription, and report.

25. The apparatus of claim 17, wherein said processor comprises at least one of a means for making a payment and a means for conducting an audit.

26. The apparatus of claim 17, wherein said processor is a component of at least one of a Wide Area Network, a Local Area Network, and a Wireless Network.

27. A patient encounter electronic medical record computer product comprising:

a processor;

an input interface configured to receive data input by a physician and an output interface coupled to said processor;

a memory configured to hold computer-readable instructions; and

a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a predetermined diagnosis;

wherein said user interface is configured to receive an input by said physician after said physician has made a diagnosis to select a subset of said diagnosis specific pre-populated templates that correspond with a the diagnosis made by the physician, and wherein said processor is configured to produce an electronic medical record from said subset of diagnosis specific pre-populated templates, said diagnosis specific pre-populated templates being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesics setting, and a therapy setting.

28. The computer product of claim 27, wherein:

said input interface includes a graphical user interface; and

said output interface includes a graphical user interface

29. The computer product of claim 27, wherein diagnosis specific pre-populated templates include at least one of specialty-specific templates and primary care templates.

30. The computer product of claim 27, wherein said processor is a component of a distributed computing system.

31. The computer product of claim 27, wherein said plurality of diagnosis specific pre-populated templates are configured for at least one of a drilldown logic and a rollup logic.

32. The computer product of claim 27, wherein said at least one of a plurality of diagnosis specific pre-populated templates comprises graphics modulated schematics.

33. The computer product of claim 27, wherein said diagnosis specific pre-populated templates are derived from at least one of a selective specialty specific database and an anatomic specific database.

34. The computer product of claim 27, wherein said diagnosis specific pre-populated templates are end-user modifiable.

35. The computer product of claim 27, wherein said input interface is configured to convert voice into text via a speech recognition mechanism.

36. The computer product of claim 27, wherein said input interface is configured to receive data of at least one of a digital image, a digital x-ray, and a wireless device.

37. The computer product of claim 27, wherein said plurality of diagnosis specific pre-populated templates are configured to include data from at least one of E/M documentation, x-rays, diagnostic studies, prescriptions, and reports.

38. The computer product of claim 30, wherein said distributed computing system comprises at least one of a payment system and an audit system.

39. The computer product of claim 30, wherein said distributed computing system comprises at least one of a Wide Area Network, a Local Area Network, and a Wireless Network.

40. A method for recording a patient encounter electronic medical record, comprising the steps of:

holding a plurality of diagnosis specific pre-populated templates with default entries in a memory and accessible by a processor;

making a diagnosis by a physician;

retrieving a subset of the plurality of diagnosis specific pre-populated templates that correspond with the diagnosis made by the physician, said retrieving step being performed after said step of making a diagnosis;

verifying said default entries and changing as necessary said default entries in said subset of the diagnosis specific pre-populated templates by a physician input; and

producing an electronic medical record from said subset of diagnosis specific prepopulated templates and entries associated therewith, after said verifying step, wherein

said diagnosis specific pre-populated templates being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesics setting, and a therapy setting.

41. The method of claim 40, wherein said retrieving step includes at least one of a drilldown processing step and a rollup processing step.

42. The method of claim 40, wherein said diagnosis specific pre-populated templates include at least one of specialty-specific templates and primary care templates.

43. The method of claim 40, further comprising:

deriving said diagnosis specific pre-populated templates from at least one of a selective specialty specific database and an anatomic specific database.