METHOD AND SYSTEM FOR AUTOMATED MEDICAL RECORDS PROCESSING

• US 20100094657A1
• Filed: 11/20/2009
• Published: 04/15/2010
• Est. Priority Date: 10/29/2002
• Status: Active Grant

• Current Assignee: Practice Velocity
• Original Assignee: Practice Velocity
• Inventors: KOEHLER, John J., STERN, David E.
• Granted Patent: US 8,606,594 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 40/63 for local operation

Abstract

A method and system for automated medical records processing. The method and system includes plural electronic medical templates specifically designed such that they reduce the complexity and risk associated with collecting patient encounter information, creating a medical diagnosis and help generate the appropriate number and type medical codes for a specific type of medical practice when processed. The medical codes and other types of processed patient encounter information are displayed in real-time on electronic medical records and invoices immediately after a patient encounter.

Claims

1. A method for automated processing of medical information, comprising:

(a) displaying via a first application on a first network device with one or more processors, one or more different electronic medical templates on a graphical user interface (GUI) on a display component on the first network device, wherein the one or more different electronic medical templates are periodically and dynamically updated on the first network device via a communications network via second application on a second network device with one or more processors and one or more associated databases and wherein the one more different medical templates include a plurality of data fields stored in a computer readable medium on the first network device comprising;

(i) patient history data,

(ii) patient physical condition data,

(iii) medical summary information,

(iv) existing patient history information, and

(v) complexity risk information;

(c) accepting patient encounter information via the GUI via the first application from a patent encounter into the plurality of data fields, thereby creating a completed electronic form for the patient encounter;

(d) aggregating medical data from the plurality of data fields on the completed electronic form and storing the aggregated medical data on the first network device in real-time, wherein the aggregated medical data is aggregated via a plurality of information matrixes stored in the computer readable medium on the first network device associated with the completed medical form including;

a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix,

wherein the HX information matrix includes a plurality of matrix information elements comprising;

a chief complaint (“

CC”

), history of present illness (“

HPI”

), past medical, family, social history information (“

PFMSH”

) elements or review of system (“

ROS”

) information elements,

wherein the PX information matrix includes a plurality of matrix information elements comprising;

(“

PF”

) exam information for a general exam;

an expanded problem focused exam (“

EXPF”

) a detailed exam (“

DET”

) or comprehensive exam (“

COMP”

) information elements,

wherein the CX information matrix includes a plurality of matrix information elements comprising;

diagnosis (“

DX”

) or treatment options information elements including a straight forward (“

SF”

) diagnosis, low risk (“

LOW”

) number of diagnosis, a moderate number of (“

MOD”

) diagnosis or a high (“

HIGH”

) number of diagnosis and a plurality of risk (“

RISK”

) information elements including straight forward (“

SF”

) risk information, low risk (“

LOW”

) information, moderate risk (“

MOD”

) information or high risk (“

HIGH”

) information;

(f) determining in real-time via the first application on the first network with the aggregated medical data via a summary information matrix a plurality of summary medical information including;

(i) one or more medical and billing codes,

(ii) one or more medical and billing code modifiers;

(iii) legal compliance for medical treatment provided to a patient during the patient encounter,

(iv) an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter,

(v) a physician practice profile by aggregating data for a particular physician,

(vi) an amount of time spent during the patient encounter;

(vii) complexity risk information,

(viii) data for use in research studies, and

(ix) billing and invoice data;

(g) displaying in real-time via the first application on the first network device via the GUI selected ones from the determined plurality summary of medical information from the patient encounter in an electronic medical record, including complexity risk information for the patient encounter, wherein the electronic medical record provides a 360 degree view of medical, billing, insurance and other information collected and generated from the patient encounter; and

(h) generating in real-time a patient invoice for the patient encounter via the electronic medical record and the one or more generated medical and billing codes.

2. A computer readable medium having stored therein instructions for causing a one or more processors to execute the steps of the method of claims 1.

3. The method of claim 1 further comprising:

verifying in real-time the aggregated medical data via the first application on the first network device.

4. The method of claim 1 wherein the one or more different electronic medical templates includes a plurality of electronic check-boxes including a plurality of different colors specifically selected for a specific type of medical practice, wherein processing the plurality of electronic check-boxes generates an appropriate number and type of medical and billing codes for the specific type of medical practice.

5. The method of claim 4, wherein the plurality of electronic check-boxes including a plurality of different colors includes a plurality of green and red check-boxes, wherein a green check box indicates medical personal examined the patient during the patient encounter, but the patient does not have any abnormality in a body area or body system indicated by the check-box and a red check box indicates the medical personal examined the patient during the patient encounter, but the patient does have one or more abnormalities in the body area or body system indicated by the check-box.

6. The method of claim 1 wherein the one or more different electronic medical templates include one or more of a medical practice template, electronic invoice template, and electronic medical record template, a current compliant template, a diagnosis template, a nurse template, a review template, or a provider template.

7. The method of claim 1 wherein the step of aggregating medical data further includes:

automatically making one or more queries to the second application on the second network device via the communications network to obtain electronic medical records or electronic medical insurance records for the patient, if any are available and extracting pre-determined values from the obtained electronic medical records and used on the one or more different medical information templates;

determining one or more history values from the HX information matrix;

determining one or more physical examination values from the PX information matrix;

determining one or more complexity risk values from the CX information matrix;

determining one or more patient status values from patient status information extracted from the patient encounter information from the HX information matrix;

determining one or more patient demographic values from patient demographic information extracted from the patient encounter information from the HX information matrix;

determining one or more diagnosis values from diagnosis information extracted from the patient encounter information from the CX information matrix;

determining one or more clinical procedure values from clinical procedure information extracted from the patient encounter information from the CX information matrix;

determining one or more supply values from supply information extracted from the patient encounter information from the HX, PX and CX information matrix; and

generating one or more medical and billing codes using the plurality of determined values via one or more summary information Evaluation and Management (E/M) information matrixes.

8. The method of claim 1 wherein the one or more medical codes and billing codes include one or more of Evaluation and Management codes (“

E/Ms”

) codes, Current Procedural Terminology (“

CPTs”

) codes, Health Care Financing Administration Common Procedural Coding System (“

HCPCS”

) codes International Classification of Diseases 9^th Edition Clinical Modification (“

ICD-9”

) codes, or International Classification of Diseases 10^th Edition Clinical Modification (“

ICD-10”

) codes.

9. The method of claim 1 wherein complexity risk coding information helps eliminate an amount and complexity of patient data to be collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed.

10. The method of claim 1 wherein the plurality of data fields include a plurality of electronic check-boxes includes generating:

a plurality of HX data fields including patient history information;

a plurality of PX data fields including patient physical condition information;

a plurality of CX data fields including complexity risk information; and

one or more Evaluation and Management (E/M) data fields including evaluation and management codes, wherein the generated one or more E/M data fields include summary information obtained by aggregating information from the HX, PX and CX data fields.

11. A method for automated processing of medical information, comprising:

aggregating patient encounter data collected from a patient encounter on an electronic medical template on a first application on a first network device with one or more processors into a plurality of information matrixes stored in a computer readable medium on the first network device associated with the first application including;

a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix, each with a plurality of matrix information fields;

wherein the CX information matrix helps eliminate an amount and complexity of patient encounter data collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a medical risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed;

generating a plurality of summary values from the plurality of information matrixes in real-time on the first application;

generating one or more medical and billing codes via one or more summary information matrixes using the plurality of summary values generated from the plurality of information matrixes in real-time on the first application;

generating an electronic patient medical record from the aggregated patient encounter data and one or more generated medical and billing codes in real-time on the first application; and

displaying in real-time via the first application on the first network device via a graphical user interface (GUI) the electronic patient medical record generated from the patient encounter including complexity risk information for the patient encounter,

wherein the electronic medical record provides a real-time 360 degree view of medical, billing, insurance and other information collected and generated from the patient encounter.

12. A computer readable medium having stored therein instructions for causing a one or more processors to execute the steps of the method of claims 11.

13. The method of claim 11 wherein the one or more medical codes and billing codes include one or more of Evaluation and Management codes (“

E/Ms”

) codes, Current Procedural Terminology (“

CPTs”

) codes, Health Care Financing Administration Common Procedural Coding System (“

HCPCS”

) codes International Classification of Diseases 9^th Edition Clinical Modification (“

ICD-9”

) codes, or International Classification of Diseases 10^th Edition Clinical Modification (“

ICD-10”

) codes.

14. The method of claim 11 wherein the step of aggregating patient encounter data further includes:

automatically making one or more queries to a second application on a second network device via a communications network to obtain electronic medical records or electronic medical insurance records for the patient, if any are available and extracting selected ones of pre-determined values from the obtained electronic medical records into a type and count of electronic check-boxes used on the electronic medical template;

aggregating patient encounter information from plurality of a electronic check-boxes selected for a specific type of medical practice and displayed on the electronic medical template;

determining the type and count of the electronic check-boxes, wherein the type and count of electronic check boxes determines one or more positions in the each of the plurality of information matrixes; and

generating one or more medical and billing codes using one or more Evaluation and Management (E/M) information matrix, wherein the positions determined from each of the plurality of information matrixes are used to determine one or more final positions in the E/M information matrix including the one or more medical and billing codes for the patient encounter.

15. The method of claim 11 further comprising:

the HX information matrix including a plurality of information elements stored in the computer readable medium comprising;

a chief complaint (“

CC”

), history of present illness (“

HPI”

), past medical, family, social history information (“

PFMSH”

) or review of system (“

ROS”

) information elements,

the PX information matrix including a plurality of information elements stored in the computer readable medium comprising;

(“

PF”

) exam information for a general exam;

an expanded problem focused exam (“

EXPF”

) a detailed exam (“

DET”

) or comprehensive exam (“

COMP”

) information elements,

the CX information matrix including a plurality of information elements stored in the computer readable medium comprising;

diagnosis (“

DX”

) or treatment options information elements including a straight forward (“

SF”

) diagnosis, low risk (“

LOW”

) number of diagnosis, a moderate number of (“

MOD”

) diagnosis or a high (“

HIGH”

) number of diagnosis and a plurality of risk (“

RISK”

) information elements including straight forward (“

SF”

) risk information, low risk (“

LOW”

) information, moderate risk (“

MOD”

) information or high risk (“

HIGH”

) information; and

one or more Evaluation and Management (E/M) summary information matrixes stored in the computer readable medium including HX matrix summary values, PX matrix summary values and CX matrix summary values for new patient encounters and established patient encounters.

16. The method of claim 11 wherein the electronic medical template includes an electronic medical template for pediatrics, obstetrics and gynecology, cardiology, neurology, family practice medicine, emergency room medicine, walk-in clinics or urgent care clinics.

17. A system for automated processing of medical information, comprising in combination:

means for displaying via a first application on a first network device with one or more processors, one or more different electronic medical templates on a graphical user interface (GUI) on a display component on the first network device, wherein the one or more different electronic medical templates are periodically and dynamically updated on the first network device via a communications network via second application on a second network device with one or more processors and one or more associated databases and wherein the one more different medical templates include a plurality of data fields stored in a computer readable medium comprising;

(i) patient history data,

(ii) patient physical condition data,

(iii) medical summary information,

(iv) existing patient history information, and

(v) complexity risk information;

means for accepting patient encounter information via the GUI via the first application from a patent encounter into the plurality of data fields, thereby creating a completed electronic form for the patient encounter;

means for aggregating medical data from the plurality of data fields on the completed electronic form and storing the aggregated medical data on the first network device, wherein the aggregated medical data is aggregated via a plurality of information matrixes stored in the computer readable medium on the first network device associated with the completed medical form including;

a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix stored in the computer readable medium,

wherein the HX information matrix includes a plurality of matrix information elements comprising;

a chief complaint (“

CC”

), history of present illness (“

HPI”

), past medical, family, social history information (“

PFMSH”

) elements or review of system (“

ROS”

) information elements,

wherein the PX information matrix includes a plurality of matrix information elements comprising;

(“

PF”

) exam information for a general exam;

an expanded problem focused exam (“

EXPF”

) a detailed exam (“

DET”

) or comprehensive exam (“

COMP”

) information elements,

wherein the CX information matrix includes a plurality of matrix information elements comprising;

diagnosis (“

DX”

) or treatment options information elements including a straight forward (“

SF”

) diagnosis, low risk (“

LOW”

) number of diagnosis, a moderate number of (“

MOD”

) diagnosis or a high (“

HIGH”

) number of diagnosis and a plurality of risk (“

RISK”

) information elements including straight forward (“

SF”

) risk information, low risk (“

LOW”

) information, moderate risk (“

MOD”

) information or high risk (“

HIGH”

) information;

means for determining via the first application on the first network with the aggregated medical data via a summary information matrix a plurality of summary medical information including;

(i) one or more medical and billing codes,

(ii) one or more medical and billing code modifiers;

(iii) legal compliance for medical treatment provided to a patient during the patient encounter,

(iv) an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter,

(v) a physician practice profile by aggregating data for a particular physician,

(vi) an amount of time spent during the patient encounter;

(vii) complexity risk information,

(viii) data for use in research studies, and

(ix) billing and invoice data;

means for displaying in real-time via the first application on the first network device via the GUI selected ones from the determined plurality summary of medical information from the patient encounter in an electronic medical record including complexity risk information for the patient encounter, wherein the electronic medical record provides a 360 degree view of medical, billing, insurance and other information collected and generated from the patient encounter; and

means for generating in real-time a patient invoice for the patient encounter via the electronic medical record and the one or more generated medical and billing codes.

18. The system of claim 17 wherein the one or more medical codes and billing codes include one or more of Evaluation and Management codes (“

E/Ms”

) codes, Current Procedural Terminology (“

CPTs”

) codes, Health Care Financing Administration Common Procedural Coding System (“

HCPCS”

) codes International Classification of Diseases 9^th Edition Clinical Modification (“

ICD-9”

) codes, or International Classification of Diseases 10^th Edition Clinical Modification (“

ICD-10”

) codes.

19. The system of claim 17, wherein the one or more different electronic medical templates includes a plurality of electronic check-boxes including a plurality of different colors specifically selected for a specific type of medical practice, wherein processing the plurality of electronic check-boxes generates an appropriate number and type of medical and billing codes for the specific type of medical practice, wherein the plurality of electronic check-boxes include a plurality of different colors including a plurality of green and red check-boxes, wherein a green check box indicates medical personal examined the patient during the patient encounter, but the patient does not have any abnormality in a body area or body system indicated by the check-box and a red check box indicates the medical personal examined the patient during the patient encounter, but the patient does have one or more abnormalities in the body area or body system indicated by the check-box.

20. The system of claim 17 wherein the one or more different electronic templates include one or more of an medical practice template, electronic invoice template, electronic medical record template, a current compliant template, a diagnosis template, a nurse template, a review template, or a provider template, wherein the medical practice template includes an electronic medical template for pediatrics, obstetrics and gynecology, cardiology, neurology, family practice medicine, emergency room medicine, walk-in clinics or urgent care clinics.