Generation of Codified Electronic Records

• US 20070260977A1
• Filed: 05/02/2006
• Published: 11/08/2007
• Est. Priority Date: 05/02/2006
• Status: Active Grant

• Current Assignee: LinkedIn Corporation (Microsoft Corporation)
• Original Assignee: International Business Machines Corporation
• Inventors: Szabo, Robert, Toohey, James, Allard, David
• Granted Patent: US 7,853,446 B2
• Time in Patent Office: Days
• US Class Current: 1/1
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A method and system for generating codified electronic records. A textual commentary can be received from a user and, in real time, the textual commentary can be analyzed to identify a plurality of codes that potentially correlate to the textual commentary. The identified codes then can be presented to the user in real time. A first user input can be received to select at least one of the identified codes, and the selected code can be added to an electronic record.

Claims

1. A method for generating a codified electronic record comprising:

receiving a textual commentary from a user;

in real time, analyzing the textual commentary to identify a plurality of codes that potentially correlate to the textual commentary, and presenting the identified codes to the user;

receiving a first user input selecting at least one of the identified codes; and

adding the selected code to the electronic record.

2. The method of claim 1, further comprising receiving a second user input to initiate at least one operation on the selected code, the operation selected from the group consisting of accepting, changing, refining, negating, and deleting the selected code.

3. The method of claim 1, wherein:

analyzing the textual commentary further comprises applying at least one text processing technique to identify at least one attribute contained in the textual commentary; and

identifying the plurality of codes comprises determining codes that correlate to the identified attribute.

4. The method of claim 1, wherein the plurality of identified codes are selected from a plurality of coding schemes.

5. The method of claim 4, wherein at least one of the plurality of coding schemes is selected from the group consisting of current procedural terminology (CPT) coding, diagnostic coding, symptom coding and prescription coding.

6. The method of claim 1, wherein receiving the textual commentary comprises receiving at least one form of commentary selected from the group consisting of a spoken utterance, typed text and hand scribed text.

7. The method of claim 1, wherein presenting the identified codes comprises presenting the identified codes in a hierarchical order.

8. The method of claim 7, wherein the hierarchical order is based, at least in part, on a code acceptance history of the identified codes.

9. The method of claim 1, further comprising:

identifying an annotation that potentially correlates to the textual commentary;

and presenting the annotation to the user.

10. The method of claim 9, further comprising receiving a second user input selecting the annotation and initiating at least one operation on the selected annotation, the operation selected from the group consisting of accepting, changing, refining, negating, and deleting the selected annotation.

11. A method for generating a codified electronic record comprising:

receiving a textual commentary from a user;

in real time, analyzing the textual conmmentary to identify a first plurality of codes that potentially correlate to the textual commentary, and presenting the first plurality of codes to the user;

receiving at least a first user input to select at least one code from the first plurality of codes and initiate at least one operation on the selected code;

presenting a second plurality of codes to the user reflecting changes caused by the operation on the selected code; and

adding the second plurality of codes to the electronic record.

12. The method of claim 11, wherein the operation is selected from the group consisting of accepting, changing, refining, negating, and deleting the selected code.

13. A machine readable storage, having stored thereon a computer program having a plurality of code sections executable by a machine for causing the machine to perform the steps of:

receiving a textual commentary from a user;

in real time, analyzing the textual commentary to identify a plurality of codes that potentially correlate to the textual commentary, and presenting the identified codes to the user;

receiving a first user input selecting at least one of the identified codes; and

adding the selected code to an electronic record.

14. The machine readable storage of claim 13, further causing the machine to perform the step of receiving a second user input to initiate at least one operation on the selected code, the operation selected from the group consisting of accepting, changing, refining, negating, and deleting the selected code.

15. The machine readable storage of claim 13, wherein:

analyzing the textual commentary further comprises applying at least one text processing technique to identify at least one attribute contained in the textual commentary; and

identifying the plurality of codes comprises determining codes that correlate to the identified attribute.

16. The machine readable storage of claim 13, wherein the plurality of identified codes are selected from a plurality of coding schemes.

17. The machine readable storage of claim 16, wherein at least one of the plurality of coding schemes is selected from the group consisting of current procedural terminology (CPT) coding, diagnostic coding, symptom coding and prescription coding.

18. The machine readable storage of claim 13 wherein receiving the textual commentary comprises receiving at least one form of commentary selected from the group consisting of a spoken utterance, typed text and hand scribed text.

19. The machine readable storage of claim 13, further causing the machine to perform the steps of:

identifying an annotation that potentially correlates to the textual commentary;

and presenting the annotation to the user.