ELECTRONIC HEALTH RECORD SYSTEM AND METHOD FOR PATIENT ENCOUNTER TRANSCRIPTION AND DOCUMENTATION

• US 20130138457A1
• Filed: 11/28/2012
• Published: 05/30/2013
• Est. Priority Date: 11/28/2011
• Status: Active Grant

• Current Assignee: Voicehit LLC
• Original Assignee: Peter Ragusa
• Inventors: Ragusa, Peter
• Granted Patent: US 9,865,025 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 10/20 for electronic clinical trials or questionnaires
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

A patient encounter documentation and analytics system includes a mobile computing platform and a server-based host platform. A mobile application in tandem with a wireless microphone collects voice signals during a patient-caregiver encounter, transforms the voice signals into audio data files, and uploads the audio data files to the server. A speech recognition software module digitally transcribes the audio data file into text. A text processing module extracts and organizes relevant clinical data based on keyword, key phrase and question/answer analysis. Relevance of words and phrases may be determined in view of, e.g., their presence, frequency and context. A diagnostic decision support module enables the healthcare provider to review the determined clinical information and provide a diagnosis associated with the encounter. A documentation skeleton module extracts diagnosis-specific text components from the transcribed text file and assembles an electronic medical document based on the diagnosis and the diagnosis-specific text components.

Claims

1. A system comprising:

a mobile computing device comprising a first processor and a first non-transitory computer-readable storage medium having program instructions residing thereon, the instructions in the first storage medium executable by the first processor to direct the performance of a process comprising

collecting voice signals during an encounter between a patient and a healthcare provider via a microphone communicatively linked to the first processor,

transforming the voice signals into one or more audio data files, and

uploading the audio data file to a host server via a communications network;

said server comprising a second processor and a second non-transitory computer-readable storage medium having program instructions residing thereon, the instructions in the second storage medium executable by the second processor to direct the performance of a process comprising

digitally transcribing the audio data file into a text file format,

determining relevant clinical information based on presence and usage of one or more predetermined text components in the text file,

enabling the healthcare provider to review the determined clinical information and provide a diagnosis associated with the encounter,

extracting diagnosis-specific text components from the transcribed text file, and

assembling an electronic medical document based on the diagnosis and the diagnosis-specific text components.

2. The system of claim 1, further comprising one or more databases including patient profile data generated based on one or more of direct input from the patient and historical data associated with the patient,

the instructions in the second storage medium further executable to direct the performance of generating a preliminary diagnosis based on the patient profile data, wherein the step of determining relevant clinical information comprises question and answer analysis of the transcribed text file based on the preliminary diagnosis.

3. The system of claim 2, wherein the step of determining relevant clinical information comprises identifying the presence of one or more predetermined keywords in the text file and categorizing associated keyword elements based on the preliminary diagnosis.

4. The system of claim 3, wherein the step of determining relevant clinical information further comprises identifying the presence of one or more predetermined key clinical phrases in the text file and scoring the relevance of the phrases.

5. The system of claim 4, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying time stamps associated with each use of the key clinical phrase and applying a value to the phrase based on a number of uses of the phrase during a period of time based on the time stamps.

6. The system of claim 4, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying time stamps associated with each use of the key clinical phrase and weighing the phrase based on the associated time stamp and a location of the phrase with respect to a predetermined block of time during the encounter.

7. The system of claim 4, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying a trigger text component within one or more of a predetermined number of words and a predetermined amount of time with respect to the phrase.

8. A method of voice recognition and medical profile transformation, the method comprising the steps of:

collecting analog voice signals during an encounter between a patient and a healthcare provider;

transforming the voice signals into one or more audio data files;

digitally transcribing the audio data file into a text file format;

determining relevant clinical information based on presence and usage of one or more predetermined text components in the text file;

enabling the healthcare provider to review the determined clinical information and provide a diagnosis associated with the encounter;

extracting diagnosis-specific text components from the transcribed text file; and

assembling an electronic medical document based on the diagnosis and the diagnosis-specific text components.

9. The method of claim 8, further comprising generating a preliminary diagnosis based on patient profile data comprising one or more of direct input from the patient and historical data associated with the patient, wherein the step of determining relevant clinical information comprises question and answer analysis of the transcribed text file based on the preliminary diagnosis.

10. The method of claim 9, wherein the step of determining relevant clinical information comprises identifying the presence of one or more predetermined keywords in the text file and categorizing associated keyword elements based on the preliminary diagnosis.

11. The method of claim 10, wherein the step of determining relevant clinical information further comprises identifying the presence of one or more predetermined key clinical phrases in the text file and scoring the relevance of the phrases.

12. The method of claim 11, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying time stamps associated with each use of the key clinical phrase and applying a value to the phrase based on a number of uses of the phrase during a period of time based on the time stamps.

13. The method of claim 11, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying time stamps associated with each use of the key clinical phrase and weighing the phrase based on the associated time stamp and a location of the phrase with respect to a predetermined block of time during the encounter.

14. The method of claim 11, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying a trigger text component within one or more of a predetermined number of words and a predetermined amount of time with respect to the phrase.

15. A non-transitory computer-readable storage medium comprising program instructions executable by a processor to direct the performance of a method comprising the steps of:

receiving an audio data file comprising audio signals generated during an encounter between a patient and a healthcare provider;

digitally transcribing the audio data file into a text file format;

determining relevant clinical information based on presence and usage of one or more predetermined text components in the text file;

enabling the healthcare provider to review the determined clinical information and provide a diagnosis associated with the encounter;

extracting diagnosis-specific text components from the transcribed text file; and

assembling an electronic medical document based on the diagnosis and the diagnosis-specific text components.

16. The computer-readable storage medium of claim 15, further comprising one or more databases including patient profile data generated based on,

the instructions in the second storage medium further executable to direct the performance of extracting patient profile data comprising one or more of direct input from the patient and historical data associated with the patient from one or more databases functionally linked to the processor;

and

generating a preliminary diagnosis based on the patient profile data,

wherein the step of determining relevant clinical information comprises question and answer analysis of the transcribed text file based on the preliminary diagnosis.

17. The computer-readable storage medium of claim 16, wherein the step of determining relevant clinical information comprises identifying the presence of one or more predetermined keywords in the text file and categorizing associated keyword elements based on the preliminary diagnosis.

18. The computer-readable storage medium of claim 17, wherein the step of determining relevant clinical information further comprises identifying the presence of one or more predetermined key clinical phrases in the text file and scoring the relevance of the phrases.

19. The computer-readable storage medium of claim 17, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying time stamps associated with each use of the key clinical phrase and applying a value to the phrase based on a number of uses of the phrase during a period of time based on the time stamps.

20. The computer-readable storage medium of claim 17, wherein scoring the relevance of a predetermined key clinical phrase comprises identifying time stamps associated with each use of the key clinical phrase and weighing the phrase based on the associated time stamp and a location of the phrase with respect to a predetermined block of time during the encounter.