Electronic record management system

• US 7,802,183 B1
• Filed: 05/17/2002
• Issued: 09/21/2010
• Est. Priority Date: 05/17/2001
• Status: Expired due to Fees

• Current Assignee: Daniel J. Essin
• Original Assignee: Daniel J. Essin
• Inventors: Essin, Daniel J.
• Primary Examiner(s): Basehoar; Adam L
• Application Number:
  US10/150,709
• Time in Patent Office: 3,049 Days
• Field of Search: 715/500, 715/500.1, 715/501.1, 715/513, 715/515, 715/764, 715/514, 715/520, 715/516, 715/201, 715/234, 715/209, 715/255, 704/1, 705/2, 705/3, 705/1, 705/4, 600/300
• US Class Current: 715/255
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• 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

Abstract

An electronic record management system utilizes semi-structured documents that contain both authenticated partial texts created by an author and pointers to audio recordings that will be processed later by transcribers. The transcribed material is held in temporary storage until reviewed and approved by the author. When approved, the transcribed text may be combined with the original authenticated partial text to produce a final authenticated document. In addition, the record management system may further include a mechanism for assigning multiple context-dependent meanings to at least a portion of the information items included in a document. The record management system therefore allows a variety of encoding schemes to be automatically overlaid on each document. This creates opportunities to re-use the information for secondary purposes, such as preparing bills (such as Medicare bills) that must conform to arbitrary sets of rules.

Claims

1. An electronic medical record management system for generating an electronic medical document based on a specific context from among a plurality of contexts within which an event may be documented, the system comprising:

means for providing one or more headings and a selection of available subheadings corresponding to each of the one or more headings;

means for receiving requests from one or more users to enter content under one or more of the selection of available subheadings corresponding to at least one of the one or more headings;

means for converting each of the one or more available subheadings for which a request to enter content has been received into a corresponding one of one or more selected subheadings;

means for receiving requests from the one or more users to associate at least one of a plurality of contexts with the one or more selected subheadings and headings; and

means for generating an electronic medical document including the entered content and the corresponding selected subheadings and headings that are associated with a specific context from among the plurality of contexts.

2. The record management system of claim 1 further comprising means for directly entering quantitative information into said electronic document.

3. The record management system of claim 2 further comprising means for generating a digitally signed message digest when said electronic document is created to provide for detection of unauthorized alteration of said electronic document.

4. The record management system of claim 1 further comprising means for creating dictation insertion points within said electronic document.

5. The record management system of claim 4 further comprising means for uniquely identifying said dictation insertion points.

6. The record management system of claim 4 further comprising means for displaying said electronic document in a workspace having a plurality of window panes, wherein said workspace displays original content of said electronic document in one of said plurality of window panes with the dictation insertion points highlighted.

7. The record management system of claim 4 means for merging transcribed material with said electronic document.

8. The record management system of claim 7 further comprising means for displaying content of said merged document, wherein non-approved transcribed material is marked with a preliminary watermark.

9. The record management system of claim 1 further comprising speech recognition means for generating a portion of content of said electronic document.

10. The record management system of claim 1 further comprising means for defining a meaning of a term as a literal constant.

11. The record management system of claim 1 further comprising means for defining a meaning of a term as a database query.

12. The record management system of claim 1 further comprising means for defining a meaning of a term as a pointer to an external lexicon or nomenclature.

13. The record management system of claim 1 further comprising means for modifying at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings.

14. The record management system of claim 13 wherein said means for modifying at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings comprises means for modifying at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings in accordance with data entry choices.

15. The record management system of claim 13 wherein said means for modifying at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings comprises means for merging at least a portion of stored electronic documents into the electronic document currently in use.

16. The record management system of claim 13 wherein the means for modifying at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings comprises programming logic stored within said electronic document that modifies at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings in accordance with content of the electronic document at a time the logic rule is invoked.

17. The record management system of claim 13, wherein the means for modifying at least a portion of said one or more headings, said selection of available subheadings, or said one or more selected subheadings comprises programming logic stored within said electronic document that modifies the information displayed within a user-interface and the behavior of the user-interface or the information that is inserted into the document being created in accordance with content of the electronic document at a time the logic rule is invoked.

18. The record management system of claim 1 further comprising means for assigning authors to one or more organizational groups or subgroups.

19. The record management system of claim 18 further comprising means for creating virtual queues for assigning a stenographer to transcribe for specific organizational groups.

20. The record management system of claim 1 further comprising means for approving said merged transcribed material.

21. The record management system of claim 1 wherein the content of said one or more selected subheadings comprises context-dependent pointers to metadata for linking said one or more selected subheadings to one or more coding schemes.

22. The record management system of claim 21 wherein said coding scheme comprises a uni-axial coding scheme.

23. The record management system of claim 21 wherein said coding scheme is a multi-axial coding scheme.

24. A method for managing electronic medical records by generating an electronic medical document based on a specific context from among a plurality of contexts within which an event may be documented, the method comprising:

providing one or more headings and a selection of available subheadings corresponding to each of the one or more headings;

receiving user requests to enter content under one or more of the selection of available subheadings corresponding to at least one of the one or more headings;

converting each of the one or more available subheadings is for which a user request to enter content has been received into a corresponding one of one or more selected subheadings;

receiving a user request to associate at least one of a plurality of contexts with the one or more selected subheadings and headings; and

generating an electronic medical document including the entered content and the corresponding selected subheadings and headings that are associated with a specific context from among the plurality of contexts.

25. The method of claim 24 wherein receiving user requests to enter content under one or more of the selection of available subheadings comprises receiving user requests to associate pointers with the one or more available subheadings to metadata for linking the one or more available subheadings to one or more coding schemes.

26. The method of claim 24 further comprising directly entering quantitative information into said electronic document.

27. The method of claim 26 further comprising generating a digitally signed message digest when said electronic document is created to provide for detection of unauthorized alteration of said electronic document.

28. The method of claim 24 further creating dictation insertion points within said electronic document.

29. A method for managing electronic medical records by generating an electronic medical document based on at least one of a plurality of contexts within which an event may be documented, the method comprising:

providing one or more headings and a selection of available subheadings corresponding to each of the one or more headings;

receiving a user request to enter content under one or more of the selection of available subheadings corresponding to at least one of the one or more headings;

converting each of the one or more available subheadings for which a user request to enter content has been received into a corresponding one of one or more selected subheadings;

associating pointers with the one or more selected subheadings to metadata for linking the one or more selected subheadings to one or more coding schemes that are context specific;

creating dictation insertion points; and

generating an electronic medical document including the entered content and the corresponding selected subheadings, headings, and dictation insertion points that are associated with pointers corresponding to at least one of the one or more context specific coding schemes.

30. An electronic medical record management system for generating an electronic medical document based on a specific context from among a plurality of contexts within which an event may be documented, the system comprising a server coupled to one or more workstations, wherein a computing device of the server or one of the one or more workstations:

provides one or more headings and a selection of available subheadings corresponding to each of the one or more headings;

receives input signals from one or more authors to enter content for association with one or more of the selection of available subheadings corresponding to at least one of the one or more headings;

converts each of the one or more available subheadings for which an input signal to enter content has been received into a corresponding one of one or more selected subheadings to be associated with a position within a structural hierarchy;

receives input signals from the one or more authors to associate one or more of a plurality of contexts with the entered content and/or selected subheadings and corresponding headings;

defines outlines for presenting the content to the one or more authors in an electronic medical document; and

generates the electronic medical document including the content and the associated selected subheadings and headings that are associated with a specific context from among the plurality of contexts.

34. The record management system of claim 30 wherein the computing device further generates a digitally signed message digest when the electronic document is created to provide for detection of unauthorized alteration of the electronic document.

35. The record management system of claim 30, wherein the computing device further receives input signals from the one or more authors to create insertion points within said electronic document and to associate the insertion points with individual dictation fragments contained within an audio recording.

36. The record management system of claim 30, wherein the computing device further displays said electronic document in a workspace having a plurality of editor window panes that have a visible and logical association with the individually numbered insertion points that are present within the document, wherein said workspace displays the content of said electronic document in an additional window pane with the dictation insertion points highlighted.

37. The record management system of claim 30, wherein at least one of the one or more workstations comprises a portable electronic device.

31. The record management system of claim wherein the computing device further enters quantitative information into said electronic document in a way that components of the quantitative information link to a terminology lexicon and the components are embedded in the electronic document as discrete elements that are automatically tagged.

32. The record management system of claim 31 wherein the components are additional descriptors that provide information necessary to correctly interpret or process the quantitative information.

33. The record management system of claim 31 wherein the quantitative information includes units of measure, duration, and anatomical location.

38. An electronic medical record management system for generating an electronic medical document based on a specific context from among a plurality of contexts within which an event may be documented, the system comprising:

means for defining snippets that constitute a semantic category;

means for linking the snippets to items of an outline, the items including one or more headings existing in a plurality of contexts, and a selection of available subheadings corresponding to each of the one or more headings;

means for receiving requests from an author to enter content under one or more of the selection of available subheadings corresponding to at least one of the one or more headings;

means for converting each of the one or more available subheadings for which a request to enter content has been received into a corresponding one of one or more selected subheadings;

means for receiving requests from the author to associate at least one of the plurality of contexts with the one or more selected subheadings and headings;

means for creating links between the snippets such that a meaning of one item of the items linked to a first snippet of the snippets can be modified or extended by a second snippet of the snippets to which it is linked; and

means for generating an electronic medical document with outline fragments that can be composed by pre-definition or dynamically, the electronic medical document including the entered content and the corresponding selected subheadings and headings that are associated with a specific context from among the plurality of contexts.

39. The electronic record management system of claim 38 further comprising:

means for selecting an outline or an outline fragment; and

means for inserting a dictation annotation into the selected outline or selected outline fragment at a point within the selected outline or selected outline fragment that is of the author'"'"'s choosing.