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

• US 6,587,830 B2
• Filed: 09/21/2001
• Issued: 07/01/2003
• Est. Priority Date: 08/13/1998
• Status: Expired due to Fees

• Current Assignee: Vitera Healthcare Solutions LLC (VCG Holdings LLC)
• Original Assignee: Medical Manager Health Systems Incorporated
• Inventors: Singer, Michael A.
• Primary Examiner(s): Stamber, Eric W.
• Assistant Examiner(s): Retta, Yehdega
• Application Number:
  US09/960,608
• Publication Number:
  US 20020087357A1
• Time in Patent Office: 648 Days
• Field of Search: 705/3, 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

A medical record processor and method include a voice processor for receiving unprompted and unstructured free dictation, for processing the dictation, and for generating voice data comprising a plurality of terms therefrom. A key term comparator identifies a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms. The identified key medical terms are separated from non-key medical terms in the generated voice data, and a non-key medical term is eliminated from the generated voice data. The identified key medical term is matched with a patient condition, and additional data are extracted from a knowledge database on the patient condition. A draft medical record is generated that includes the identified key medical term and the additional data.

Claims

1. A medical record processor comprising:

a voice processor for receiving unprompted and unstructured free dictation from medical personnel, for processing the dictation, and for generating voice data comprising a plurality of terms therefrom;

a key term comparator for identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;

a separator for separating the identified key medical terms from non-key medical terms in the generated voice data and for eliminating a non-key medical term from the generated voice data;

a medical term matcher for matching the identified key medical term with a patient condition and for extracting from a knowledge database additional data on the patient condition; and

a medical record creator for generating a draft medical record comprising the identified key medical term and the additional data.

2. The medical record processor recited in claim 1, further comprising a personnel identifier for identifying the medical personnel from whose dictation the generated voice data have come.

3. The medical record processor recited in claim 2, wherein the personnel identifier comprises a biometric identifier selected from a group consisting of a voice identifier, a fingerprint identifier, an eye characteristic identifier, a skin characteristic identifier, and a body fluid identifier.

4. The medical record processor recited in claim 2, wherein the voice processor comprises at least one of a speech learner and a pattern learner having access to at least one set of stored voice data from the identified medical personnel.

5. The medical record processor recited in claim 1, wherein the key term comparator comprises means for accessing a database containing the plurality of key medical terms.

6. The medical record processor recited in claim 1, wherein the separator comprises a natural language parser.

7. The medical record processor recited in claim 1, further comprising software means for routing the eliminated non-key medical term to a memory device for storing the eliminated non-key medical term therein.

8. The medical record processor recited in claim 1, wherein the additional data from the knowledge database comprise treatment data related to the patient condition.

9. The medical record processor recited in claim 1, wherein the comparator comprises a software subroutine.

10. The medical record processor recited in claim 1, wherein the knowledge database has a structured tree configuration for relating the patient condition to related data including at least one of a treatment, a symptom, and a diagnosis.

11. The medical record processor recited in claim 1, further comprising a revisor in electronic communication with a user interface for receiving and implementing a user revision to the draft medical record to create an accepted medical record.

12. The medical record processor recited in claim 11, wherein the user interface comprises at least one of a display terminal, a keyboard, a pointing device, and a printer.

13. The medical record processor recited in claim 12, wherein the revisor comprises means for matching the user revision with data in the knowledge database.

14. The medical record processor recited in claim 13, wherein the matching means comprises a best-fit comparing software routine.

15. The medical record processor recited in claim 11, further comprising a medical record storage routine for storing the accepted medical record.

16. The medical record processor recited in claim 15, further comprising means for adding an acceptance identifier to the accepted medical record.

17. The medical record processor recited in claim 1, further comprising a medical record storage routine for storing the draft medical record.

18. A medical record processing system comprising:

a voice input device;

a voice processor for receiving unprompted and unstructured free dictation from a medical personnel via the voice input device, for processing the dictation, and for generating voice data comprising a plurality of terms therefrom;

a key term comparator for identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;

a separator for separating the identified key medical terms from non-key medical terms in the generated voice data and for eliminating a non-key medical term from the generated voice data;

a medical term matcher for matching the identified key medical term with a patient condition and for extracting from a knowledge database additional data on the patient condition; and

a medical record creator for generating a draft medical record comprising the identified key medical term and the additional data.

19. The system recited in claim 18, wherein the voice input device comprises a voice recorder.

20. The system recited in claim 18, further comprising a personnel identifier for identifying the medical personnel from whose dictation the generated voice data have come.

21. The system recited in claim 18, further comprising a key medical term database containing the plurality of key medical terms, and wherein the key term comparator comprises means for accessing the key medical term database.

22. The system recited in claim 18, wherein the separator comprises a natural language parser.

23. The system recited in claim 18, further comprising a memory device for storing the eliminated non-key medical term and software means for routing the eliminated non-key medical term thereto.

24. The system recited in claim 18, further comprising a storage device whereon the knowledge database resides.

25. The system recited in claim 24, wherein the additional data from the knowledge database comprise treatment data related to the patient condition.

26. The system recited in claim 24, wherein the comparator comprises a software subroutine having means for accessing the storage device.

27. The system recited in claim 24, wherein the knowledge database has a structured tree configuration for relating the patient condition to related data including at least one of a treatment, a symptom, and a diagnosis.

28. The system recited in claim 18, further comprising a user interface and a revisor in electronic communication with the user interface for receiving and implementing a user revision to the draft medical record to create an accepted medical record.

29. The system recited in claim 28, wherein the user interface comprises at least one of a display terminal, a keyboard, a pointing device, and a printer.

30. The system recited in claim 28, wherein the revisor comprises means for matching the user revision with data in the knowledge database.

31. The system recited in claim 30, wherein the matching means comprises a best-fit comparing software routine.

32. The system recited in claim 28, further comprising a storage device and a medical record storage routine for storing the accepted medical record on the storage device.

33. The system recited in claim 32, further comprising means for adding an acceptance identifier to the accepted medical record.

34. The system recited in claim 18, further comprising a storage device and a medical record storage routine for storing the draft medical record on the storage device.

35. A method for processing an orally delivered medical record comprising the steps of:

receiving unprompted and unstructured free dictation from medical personnel;

processing the dictation and generating voice data comprising a plurality of terms from the processed dictation;

identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;

separating the identified key medical terms from non-key medical terms in the generated voice data and eliminating a non-key medical term from the generated voice data;

matching the identified key medical term with a patient condition and extracting from a knowledge database additional data on the patient condition; and

generating a draft medical record comprising the identified key medical term and the additional data.

36. The medical record processing method recited in claim 35, further comprising the step of identifying the medical personnel from whose dictation the generated voice data have come.

37. The medical record processing method recited in claim 35, wherein the personnel identifying step comprises the step of performing a biometric identification.

38. The medical record processing method recited in claim 35, wherein the processing step comprises the step of using at least one of a speech learner and a pattern learner having access to at least one set of stored voice data from the identified medical personnel.

39. The medical record processing method recited in claim 35, wherein the identifying step comprises accessing a database containing the plurality of key medical terms.

40. The medical record processing method recited in claim 35, wherein the separating step comprises per forming natural language parsing.

41. The medical record processing method recited in claim 35, further comprising the step of storing the eliminated non-key medical term in a memory device.

42. The medical record processing method recited in claim 35, wherein the additional data from the knowledge database comprise treatment data related to the patient condition.

43. The medical record processing method recited in claim 35, wherein the extracting step comprises the step of relating the patient condition to related medical data including at least one of a treatment, a symptom, and a diagnosis.

44. The medical record processing method recited in claim 35, further comprising the steps of receiving and implementing a user revision to the draft medical record to create an accepted medical record.

45. The medical record processing method recited in claim 44, wherein the implementing step comprises the step of matching the user revision with data in the knowledge database.

46. The medical record processing method recited in claim 45, wherein the matching step comprises the step of performing a best-fit comparison.

47. The medical record processing method recited in claim 45, further comprising the step of storing the accepted medical record.

48. The medical record processing method recited in claim 47, further comprising the step of adding an acceptance identifier to the accepted medical record.

49. The medical record processing method recited in claim 35, further comprising the step of storing the draft medical record.

50. A medical record processing method comprising the steps of:

inputting unprompted and unstructured free dictation from a medical personnel into a voice input device;

receiving the dictation from the voice input device;

processing the dictation and generating voice data comprising a plurality of terms therefrom;

identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;

separating the identified key medical terms from non-key medical terms in the generated voice data and eliminating a non-key medical term from the generated voice data;

matching the identified key medical term with a patient condition and extracting from a knowledge database additional data on the patient condition; and

generating a draft medical record comprising the identified key medical term and the additional data.

51. The medical record processing method recited in claim 50, further comprising the step of identifying the medical personnel from whose dictation the generated voice data have come.

52. The medical record processing method recited in claim 50, further comprising the step of accessing a key medical term database containing the plurality of key medical terms.

53. The medical record processing method recited in claim 50, wherein the separating step comprises the step of performing natural language parsing.

54. The medical record processing method recited in claim 50, further comprising the step of storing the eliminated non-key medical term in a memory device.

55. The medical record processing method recited in claim 50, wherein the extracting step comprises the step of accessing a storage device whereon the knowledge database resides.

56. The medical record processing method recited in claim 55, wherein the additional data from the knowledge database comprise treatment data related to the patient condition.

57. The medical record processing method recited in claim 50, wherein the knowledge database has a structured tree configuration for relating the patient condition to related data including at least one of a treatment, a symptom, and a diagnosis.

58. The medical record processing method recited in claim 50, further comprising the steps of receiving and implementing a user revision to the draft medical record to create an accepted medical record.

59. The medical record processing method recited in claim 58, wherein the implementing step comprises the step of matching the user revision with data in the knowledge database.

60. The medical record processing method recited in claim 59, wherein the matching step comprises the step of performing a best-fit comparison.

61. The medical record processing method recited in claim 50, further comprising the step of storing the accepted medical record.

62. The medical record processing method recited in claim 61, further comprising the step of adding an acceptance identifier to the accepted medical record.

63. The medical record processing method recited in claim 50, further comprising the step of storing the draft medical record.