Medical record forming and storing apparatus and medical record and method related to same

• US 6,304,848 B1
• Filed: 08/13/1998
• Issued: 10/16/2001
• Est. Priority Date: 08/13/1998
• Status: Expired due to Fees

• Current Assignee: Vitera Healthcare Solutions LLC (VCG Holdings LLC)
• Original Assignee: Medical Manager Corp. (WebMD Health Corporation)
• Inventors: Singer, Michael A.
• Primary Examiner(s): Stamber, Eric W.
• Assistant Examiner(s): Retta, Yehdega
• Application Number:
  US09/133,548
• Time in Patent Office: 1,160 Days
• Field of Search: 705/3, 705/2, 704/3, 704/215, 704/240, 704/251, 704/254, 704/255, 704/270
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G10L 2015/088 Word spotting
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

An apparatus and method for forming medical records and a medical record formed thereby are provided. The apparatus preferably includes a voice input device for inputting free dictation of medical personnel, a voice processor responsive to the voice input device for processing the inputted voice and generating voice data therefrom, and a key term recognizer responsive to the voice processor for recognizing key medical terms freely dictated by the medical personnel. The key term recognizer preferably includes a key medical term database for storing a plurality of key medical terms therein. The apparatus preferably also includes a medical term matcher responsive to the key word recognizer for matching recognized key medical terms used by the medical personnel at least with patient conditions to thereby add additional data thereto and a medical record creator responsive to the medical term matcher for creating an actual patient medical record therefrom. A method of forming medical records preferably includes generating a plurality of key medical terms, recognizing the plurality of key medical terms responsive to a key medical term database having a plurality of key medical terms stored therein, matching recognized key medical terms used by the medical personnel at least with known patient conditions stored in a knowledge database so that the knowledge database assists in further describing the actual condition of the patient by adding additional data thereto, and creating an actual patient medical record responsive to the matched recognized key medical terms.

Claims

1. A medical record forming and storing apparatus comprising:

voice inputting means for inputting unprompted and unstructured free dictation of at least one medical personnel;

voice processing means responsive to said voice inputting means for processing the inputted voice from said voice inputting means and generating voice data therefrom;

key term recognizing means responsive to said voice data processing means for recognizing key medical terms freely dictated in an unstructured and unprompted format by the at least one medical personnel, said key term recognizing means including key medical term storing means for storing a plurality of key medical terms, comparing means responsive to said key medical term storing means for comparing the voice data with key medical terms within said key medical term storing means, separating means responsive to said comparing means for separating the key medical terms from the non-key medical terms, and non-key term eliminating means for eliminating non-key terms from the generated voice data;

medical term matching means responsive to said key term recognizing means for matching medical terms used by the medical personnel at least with patient conditions, said medical term matching means including a knowledge database for assisting in further describing the actual condition of the patient by adding additional data thereto; and

medical record creating means responsive to said medical term matching means for creating an actual patient medical record, said medical record creating means including draft record generating means for generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, record revising means responsive to the at least one medical personnel for revising the draft medical record, and record accepting means responsive to medical personnel for accepting the draft medical record.

2. An apparatus as defined in claim 1, further comprising medical record storing means responsive to said medical record creating means for storing an accepted medical record created therefrom for future reference.

3. An apparatus as defined in claim 1, wherein said knowledge database includes a structured tree configuration.

4. An apparatus as defined in claim 1, wherein said voice processing means includes speech term learning means for learning speech terms used by identified medical personnel.

5. An apparatus as defined in claim 1, wherein said voice processing means includes speech pattern learning means for learning speech patterns used by identified medical personnel.

6. An apparatus as defined in claim 1, further comprising biometric identifying means connected to said voice processing means for identifying biometric data from medical personnel to thereby reference previous terms or patterns from previous dictations to the apparatus by the identified medical personnel.

7. An apparatus as defined in claim 1, wherein said key term recognizing means further includes non-key term storing means responsive to said non-key term eliminating means for storing the eliminated non-key terms for future reference.

8. An apparatus as defined in claim 1, wherein said record revising means includes knowledge database revised term matching means responsive to said knowledge database for matching terms revised by the at least one medical personnel with terms in said knowledge database.

10. An apparatus as defined in claim 1, further comprising a medical personnel user interface responsive to said medical record creating means for providing a user interface to medical personnel so that draft medical records can be revised.

9. A medical record forming and storing apparatus comprising:

voice inputting means for inputting unprompted and unstructured free dictation of at least one medical personnel;

voice processing means responsive to said voice inputting means for processing the inputted voice from said voice inputting means and generating voice data therefrom;

key term recognizing means responsive to said voice data processing means for recognizing key medical terms freely dictated in an unstructured and unprompted format by the at least one medical personnel, said key term recognizing means including key medical term storing means for storing a plurality of key medical terms, comparing means responsive to said key medical term storing means for comparing the voice data with key medical terms within said key medical term storing means, and separating means responsive to said comparing means for separating the key medical terms from the non-key medical terms;

medical term matching means responsive to said key term recognizing means for matching medical terms used by the medical personnel at least with patient conditions, said medical term matching means including a knowledge database for assisting in further describing the actual condition of the patient by adding additional data thereto; and

medical record creating means responsive to said medical term matching means for creating an actual patient medical record, said medical record creating means including draft record generating means for generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, record revising means responsive to the at least one medical personnel for revising the draft medical record, the record revising means including knowledge database revised term matching means responsive to said knowledge database for matching terms revised by the at least one medical personnel with terms in said knowledge database, the knowledge database revised term matching means including best-fit comparing means for comparing the revised term with terms within said knowledge database based upon a best-fit matching configuration, and record accepting means responsive to medical personnel for accepting the draft medical record.

11. A medical recording forming and storing apparatus comprising:

a voice input device for inputting unprompted and unstructured free dictation of at least one medical personnel;

a voice processor responsive to said voice input device for processing the inputted voice and generating voice data therefrom;

a key term recognizer responsive to said voice processor for recognizing key medical terms freely dictated by the at least one medical personnel, said key term recognizer including a key medical term database for storing a plurality of key medical terms therein and a non-key term eliminator for eliminating non-key terms from the generated voice data;

a medical term matcher responsive to said key word recognizer for matching recognized key medical terms used by the at least one medical personnel at least with patient conditions to thereby add additional data thereto, including a knowledge database having a structured tree configuration which relates patient conditions with patient treatments of the conditions so that the knowledge database assists in further describing the actual condition of the patient by adding additional data thereto;

a medical record creator responsive to said medical term matcher for creating an actual patient medical record therefrom;

medical record storing means responsive to said medical record creator for storing an accepted medical record created therefrom for future reference.

12. An apparatus as defined in claim 11, wherein said voice processor includes a speech term learner for learning speech terms used by identified medical personnel.

13. An apparatus as defined in claim 11, wherein said voice processor includes a speech pattern learner for learning speech patterns used by identified medical personnel.

14. An apparatus as defined in claim 11, further comprising a biometric identifier connected to said voice processor for identifying biometric data from medical personnel to thereby reference previous terms or patterns from previous dictations to the apparatus by the identified medical personnel.

15. An apparatus as defined in claim 11, wherein said key term recognizer further includes non-key term storing means responsive to said non-key term eliminator for storing the eliminated non-key terms for future reference.

16. An apparatus as defined in claim 15, wherein said medical record creator includes a draft record generator for generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, a record revisor responsive to the at least one medical personnel for revising the draft medical record, and record acceptor responsive to medical personnel for accepting the draft medical record.

17. An apparatus as defined in claim 16, wherein said record revisor includes a knowledge database revised term matcher responsive to said knowledge database for matching terms revised by the at least one medical personnel with terms in said knowledge database.

18. An apparatus as defined in claim 17, wherein said knowledge database revised term matcher includes a best-fit comparator for comparing the revised term with terms within said knowledge database based upon a best-fit matching configuration.

19. An apparatus as defined in claim 18, further comprising a medical personnel user interface responsive to said medical record creator for providing a user interface to medical personnel so that draft medical records can be revised.

20. A medical record forming apparatus comprising:

voice inputting means for inputting dictation of at least one medical personnel;

voice processing means responsive to said voice inputting means for processing the inputted voice from said voice inputting means and generating voice data therefrom;

key term recognizing means responsive to said voice processing means for recognizing key medical terms dictated the at least one medical personnel, said key term recognizing means including key medical term storing means for storing a plurality of key medical terms, comparing means responsive to said key medical term storing means for comparing the voice data with key medical terms within said key medical term storing means, separating means responsive to said comparing means for separating the key medical terms from the non-key medical terms, and non-key term eliminating means for eliminating non-key terms from the generated voice data;

medical term matching means responsive to said key term recognizing means for matching medical terms used by the medical personnel at least with patient conditions, said medical term matching means including a knowledge database relating patient conditions with patient treatments of the conditions so that the knowledge database assists in further describing the actual condition of the patient by adding additional data thereto; and

medical record creating means responsive to said medical term matching means for creating an actual patient medical record, said medical record creating means including draft record generating means for generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, record revising means responsive to the at least one medical personnel for revising the draft medical record, and record accepting means responsive to medical personnel for accepting the draft medical record.

21. An apparatus as defined in claim 20, further comprising medical record storing means responsive to said medical record creating means for storing an accepted medical record created therefrom for future reference.

22. An apparatus as defined in claim 21, wherein said knowledge database includes a structured tree configuration.

23. An apparatus as defined in claim 22, wherein said voice processing means includes speech term learning means for learning speech terms used by identified medical personnel.

24. An apparatus as defined in claim 23, wherein said voice processing means includes speech pattern learning means for learning speech patterns used by identified medical personnel.

25. An apparatus as defined in claim 24, further comprising biometric identifying means connected to said voice processing means for identifying biometric data from medical personnel to thereby reference previous terms or patterns from previous dictations to the apparatus by the identified medical personnel.

26. An apparatus as defined in claim 22, wherein said key term recognizing means further includes non-key term storing means responsive to said non-key term eliminating means for storing the eliminated non-key terms for future reference.

27. An apparatus as defined in claim 22, wherein said record revising means includes knowledge database revised term matching means responsive to said knowledge database for matching terms revised by the at least one medical personnel with terms in said knowledge database.

28. An apparatus as defined in claim 27, wherein said knowledge database revised term matching means includes best-fit comparing means for comparing the revised term with terms within said knowledge database based upon a best-fit matching configuration.

29. An apparatus as defined in claim 28, further comprising a medical personnel user interface responsive to said medical record creating means for providing a user interface to medical personnel so that draft medical records can be revised.

30. A method of forming medical records comprising the steps of:

inputting unprompted and unstructured free dictation of at least one medical personnel;

processing the inputted voice to thereby generate voice data therefrom;

recognizing key medical terms freely dictated by the at least one medical personnel responsive to a key medical term database having a plurality of key medical terms stored therein, including the step of eliminating non-key terms from the generated voice data;

matching recognized key medical terms used by the at least one medical personnel at least with known patient conditions to thereby add additional data thereto, including providing a knowledge database having a structured tree configuration which relates patient conditions with patient treatments of the conditions so that the knowledge database assists in further describing the actual condition of the patient by adding additional data thereto;

creating an actual patient medical record therefrom; and

storing a created actual medical record accepted by the at least one medical personnel for future reference.

31. A method as defined in claim 30, wherein the processing step includes learning speech terms used by identified medical personnel.

32. A method as defined in claim 30, wherein the processing step includes learning speech patterns used by identified medical personnel.

33. A method as defined in claim 30, further comprising identifying biometric data from medical personnel to thereby reference previous terms or patterns from previous dictations by the identified medical personnel.

34. A method as defined in claim 30, wherein the recognizing step further includes storing the eliminated non-key terms for future reference.

35. A method as defined in claim 30, wherein the creating step includes generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, revising the draft medical record responsive to the at least one medical personnel, and accepting the draft medical record.

36. A method as defined in claim 35, wherein the revising step includes providing a knowledge database revised term matcher responsive to the knowledge database for matching terms revised by the at least one medical personnel with terms in the knowledge database.

37. A method as defined in claim 36, wherein the knowledge database revised term matcher includes a best-fit comparator for comparing the revised term with terms within the knowledge database based upon a best-fit matching configuration.

38. A method as defined in claim 37, further comprising providing a user interface to medical personnel so that the draft medical records can be revised.

39. A method of forming medical records comprising the step of:

inputting dictation of at least one medical personnel;

processing the inputted voice to thereby generate voice data therefrom;

recognizing key medical terms dictated by the at least one medical personnel responsive to a key medical term database having a plurality of key medical terms stored therein and eliminating non-key terms from the generated voice data;

matching recognized key medical terms used by the at least one medical personnel at least with known patient conditions; and

providing a knowledge database having a structured tree configuration for assisting in further describing the actual condition of the patient by adding additional data thereto.

40. A method as defined in claim 39, further comprising creating an actual patient medical record responsive to the matched recognized key medical terms and storing a created medical record accepted by the at least one medical personnel for future reference.

41. A method as defined in claim 39, wherein the structure tree of said knowledge database includes at least a root node and a plurality of leaf nodes.

42. A method as defined in claim 39, wherein the processing step includes learning speech terms used by identified medical personnel.

43. A method as defined in claim 42, wherein the processing step includes learning speech patterns used by identified medical personnel.

44. A method as defined in claim 43, further comprising identifying biometric data from medical personnel to thereby reference previous terms or patterns from previous dictations by the identified medical personnel.

45. A method as defined in claim 44, wherein the recognizing step further includes storing the eliminated non-key terms for future reference.

46. A method as defined in claim 40, wherein the creating step includes generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, revising the draft medical record responsive to the at least one medical personnel, and accepting the draft medical record.

47. A method as defined in claim 46, wherein the revising step includes providing a knowledge database revised term matcher responsive to the knowledge database for matching terms revised by the at least one medical personnel with terms in the knowledge database.

48. A method as defined in claim 47, wherein the knowledge database revised term matcher includes a best-fit comparator for comparing the revised term with terms within the knowledge database based upon a best-fit matching configuration.

49. A method as defined in claim 48, further comprising providing a user interface to medical personnel so that the draft medical records can be revised.

50. A method of forming medical records comprising the step of:

generating a plurality of key medical terms;

recognizing the plurality of key medical terms responsive to a key medical term database having a plurality of key medical terms stored therein, including eliminating non-key terms from generated data;

matching recognized key medical terms used by the at least one medical personnel at least with known patient conditions stored in a knowledge database which relates patient conditions with patient treatments of the conditions so that the knowledge database assists in further describing the actual condition of the patient by adding additional data thereto; and

creating an actual patient medical record responsive to the matched recognized key medical terms, including generating a draft medical record related to the at least one medical personnel'"'"'s dictation for review by the at least one medical personnel, revising the draft medical record responsive to the at least one medical personnel, and accepting the draft medical record.

51. A method as defined in claim 50, further comprising storing a created medical record accepted by at least one medical personnel for future reference.

52. A method as defined in claim 50, wherein the recognizing step further includes storing the eliminated non-key terms for future reference.

53. A method as defined in claim 50, wherein the revising step includes providing a knowledge database revised term matcher responsive to the knowledge database for matching terms revised by the at least one medical personnel with terms in the knowledge database.

54. A method as defined in claim 53, wherein the knowledge database revised term matcher includes a best-fit comparator for comparing the revised term with terms within the knowledge database based upon a best-fit matching configuration.

55. A method as defined in claim 54, further comprising providing a user interface to medical personnel so that the draft medical records can be revised.